Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Approaching Your First Job. My name is Michael DeLutre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so please feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI Fellow moderator, Dr. Faisal Mahmood from Honor Health in Scottsdale, Arizona. I will now hand over this presentation to him. My name is Faisal Mahmood. I'm a gastroenterology fellow at Honor Health in Scottsdale, Arizona. So it's my pleasure to be a part of this ASGE webinar. So I'm going to move forward and introduce our content experts. We have Dr. Neel Sharma. He is a program director for interventional endoscopy fellowship at Peak Gastroenterology Associates in Colorado Springs, Colorado, and he's also a director of interventional endoscopy programs for Peak and GastroCare partners. And he's also an associate professor of medicine and a chair of editorial review board of innovation in gastrointestinal endoscopy. We have Dr. Natalie Koskoff. She's interventional endoscopy center for interventional endoscopy at AdventHealth Orlando, and she's also a director of quality and safety for Digestive Health Institute. And we have Dr. Dennis Chen. He is an interventional endoscopist at University of Chicago and an assistant professor of medicine. Okay. So we will be actually having open-ended discussion. We actually compiled a few questions that we can start and move forward, but you guys can also keep posting your questions in Q&A and I or the other panelists will be checking the Q&A box periodically and answering those questions as well. So the first thing is like finding the right job. So and first question comes up is like, when should we start looking for our first job? I'm going to start with like our panelists and they are going to take turns and answer that question. So at what point we should start looking for the job? Like some say in second year, some in third year, like is there any appropriate time in that we can move forward and start looking for the jobs? Maybe Dr. Chen, you can start. Sure. I think starting earlier is always reasonable. You don't want to be scrambling in February, March looking for a job to start in July because between the interview process, the credentialing process, getting your licenses, it can drag on for quite a while. So earlier is better. You know, the challenge with some of the job process is that timing is different, right? You're no longer on the application cycle like you are for various fellowships. So jobs may be available at the time when you ask or they may not. Job openings show up at different times. And then one of the other things that is kind of will be a new experience for a lot of folks coming out of fellowship is that if you interview for a job and you get to an offer, you might get a deadline and have to answer to that before you've gone through all the other jobs that you were looking to interview at and you'll have to make a decision on that. But overall, I think earlier is better. It gives you more options and if you don't find something that fits, you still have time to move and keep looking for other jobs. Probably I'd say a reasonable starting time would be beginning of third year, basically beginning of the academic year before you're about to graduate is probably a reasonable time frame. I don't know if Neil and Natalie feel differently or have other thoughts to input here. Yeah, I agree. I don't think you can do it too soon, although like like Dennis said, if you're looking soon, just know that a place isn't going to wait several years for you to make a decision. They'll probably want you to make a decision within a reasonable time. But if you have a very specific geographic area that you want to be in or a very specific group that you want to join, it's probably better to start those discussions early so you can get kind of things locked down before the position is taken by somebody else. Yeah, I would just say that Dennis and Natalie both bring up some really key points. Dennis mentioned trying to start early and not scramble at the end. I would definitely echo that. And then Natalie mentioned that if you have a specific location, that's important. And so if you know yourself and you kind of know what it is that you're hoping to either have in specific criteria within a job or even more so a specific location, then it's better to start early. Right. And specific locations, as Natalie pointed out, are extremely important because some areas are more saturated than others relative to the job market. And especially if you have a subspecialty within GI. And so if you do have that and you know where you want to go, you can start as early as first year. If you're wide open, you're looking all over the country, then there may be other factors such as economics, the profile of the job, work-life balance that are more important than location. You may have more time and you want to look a little bit more. And personally, I think there are so many fellows who are on J-1 visa and I came across a few friends, they are like they have to find and sign their contract by the end of this year because J-1 technically starts. You have to find a waiver job at least I think one and a half year or two years before it starts. They have to finalize their job search by the middle of second year, I think. That's a great point. Yeah. Okay. All right. So the next question is, how can you find out job opportunities? There are certain websites like Practice Link or Glassdoor or other like JAMA, they have the career opportunities or NEGM or maybe some other link like Colleague Working at the Institution. So what do you recommend? What should be our strategy to look for a job? I think links are helpful. Some job opportunities are published like in GI journals, but to be honest, and I'd be interested on the rest of the panel's thoughts, most jobs are not listed. A lot of it's word of mouth. When I was starting out and finding my first job, I wanted to stay in academics and I would ask my attendings, hey, do you think this place is hiring? And one of the things I think would be the best advice I would give is don't listen if anyone says no. And they're not, it's not that they're lying to you, they just don't know. I would ask my attendings do you think this place is hiring? No, I don't think so. They just hired so and so. I don't think they're hiring. And then I would email them anyway and they'd say, yeah, yeah, we are hiring. We just decided recently that we want to hire someone else. So don't kind of be limited by word of mouth. Don't be limited by what is in, what is posted. Posted opportunities, certainly you can look through those. But personally, what I did and I was lucky I wasn't really limited geographically. I went through a map and I looked at all the academic institutions that I'd be interested in and I mass emailed all of them. The chief of GI, if I had any contacts in the institution, and I found out about a lot of jobs that were hiring or looking for specific people that I would not have heard about otherwise. Yeah, my experience, I would say going into academic jobs is very similar to what Natalie said, is that you can ask your faculty mentors what they know and what contacts they have. But a lot of what you probably will do in an academic setting is you're going to cold email people and just say, hey, I'm looking for a job and are you hiring and have your cover letter ready and send it to them, have your CV ready and send it to them. And as Natalie said, like a lot of times, even if no one knew that they were hiring, the answer is sure, we're looking. Yeah, I think it helps to know kind of what it is that you want to do. So if there's specific criteria of a job, and I think for us, you just happen to have three interventional endoscopists all on at once. We have some specifics of what we're all looking for, right? And we all want to do all interventional work. I think I speak for all three of us when we do that. So for us, that automatically limits our criteria. And so when I look at the global aspect of this question, it's if you have some limitations and it's not a negative limitation like for us, we pursued an additional fellowship to do what we do. It just makes your job requirements a little bit more narrow. It's better to then pursue those things. And as Natalie pointed out, you know, be aggressive in your pursuit because you'll be surprised how much the job market's open. I would just say one other thing, and this is the context of the totality of the talk tonight, you know, the GI job market relevant to the rest of perhaps internal medicine specialties. It's really wide open right now, and there's a real dearth of GI physicians in all categories, regardless of whether you have a subspecialty focused or if you're a generalist. And so understanding that, understanding the supply and demand of the marketplace will work in your favor. And so this means that there's a lot of openings. You'll be surprised. I just recently switched from my very first job to this job that I'm currently in Colorado. And it's just, you know, it's a wide open marketplace. So just keep that in your back pocket as we talk about the context of the rest of this lecture, because it could vary from year to year, but it's a really good time right now to be a GI physician. Next question is what factor should you consider when looking for a job? I think like we mentioned before, it's really going to be personal to you. And I think that's something that I didn't realize until midway through my job search. Because I was getting a lot of input from mentors, and they all had different ideas of what an ideal job would be. And the truth is, it really depends what you're looking for, what you want your career to be. If you have any restrictions, like by geographic, if you have a spouse or a family to consider, that certainly comes into play. If you want to do, you know, research, if you need a specific type of specialty. So really, all those factors, and then quality of life, being closer to family, if you need to travel or have a spouse that needs to travel, where's the closest airport, what's the cost of living. So really, it's the first time, at least for me, that factors kind of outside of my career came into play as far as just what type of environment I want to live in, not just the job, but also geographically. Yeah, I guess I would say, I agree 100% with what Natalie's saying. And one of the advice, piece of advice I give my fellows when we talk about this, is to think about what's actually important to you, like everyone was saying. And sometimes it's a difficult transition to make, because I assume almost everyone in attendance is a fellow currently, which means that you have probably done a lot of things to make yourself look academically appealing to the fellowship programs that you're applying to. And you've said things that may or may not be fully truthful about your career interests and long term interests, because you know, that's what the fellowship is looking for. You might have taken a fellowship at a place where you knew factor A, B, or C, whether it's the job you're applying to, or whether it's the job you're applying to. And factor A, B, or C, whether it's geography, or something about the program wasn't ideal, but you knew, I'm going to be here for three years, I'm going to get what I need out of it, and then I can move on. And now when you're looking for your job, it's really important to be honest with yourself and think what actually is important for you. Because if you've done a ton of research and publish 80 things as a fellow to get to this point, but you actually have no interest in long term as research, you should not look for a job where they're going to ask you to spend 50% of your time doing clinical research if you're not going to be into that. And it's hard, I think, for a lot of people to wrap their mind around the idea of what do you actually want? Because now you are an asset when you're being interviewed for jobs. And so these places are working just as hard to recruit you as you are trying to impress them. Yeah, great points. You know, I think this question around what factors do you consider looking for a job? And then how do I decide what's the best job? Kind of blend together, right? And it begins with knowing yourself. And you know, when you come through, you've done what, at least three years of internal medicine, three years of fellowship, and you've kind of been at the beck and call of someone else to do what you need to do to be a quote, good fellow and also acquire certain skill sets. But then at this point in time, I always tell our advanced fellows, I have an advanced fellow right now, and we start at the very beginning of the year and just say, okay, what are the things that are important to you that you want to get out of the year in terms of skill sets, knowledge, personal growth, or personal characteristic growth. But I also start to encourage them at the end of the year to make sure that they know what they want. Now, many come in at that point, they're PGY7 of gas specific criteria of location or work life balance or expectations around what my work day would look like or balance between clinical split, academics, time for teaching, time for research and or administrative possibilities. So you want to list all those things down, right? When you look at your job split, you want to look at, you know, what are my criteria? So and then what's the priority of those criteria? So if location is your top priority, then everything else is going to fall from there. If economics are your top priority, everything will fall from there. But the major categories would be location, economics, and then what does your actual work day or work week look like in terms of a breakdown of different categories, those being predominantly clinical research, teaching, academic time, and then finally some time if you have an interest in administration. And then of course, and I think we're all probably guilty of this, but I know I was really bad about it, work life balance, because I never thought that you needed the balance part. And you might be coming out of fellowship with that same mentality. So put that somewhere on the list. Yeah, I think for me, I drove myself crazy trying to pick between jobs, because there's so many variables. But one of the things that helped me is by the end of it, when I had to make my decision, I had a list of must-haves and a list of can't-haves. And that really helped me break down the opportunities to see what really fit into what I was looking for, because everything can't be equally as infinite. Okay, so the next is the interview process for your job. So what can I expect during the interview process, and how should I prepare for that? Let me just say it's all relevant to job market, right? So this is really a medical-based answer, but it's the answer that makes sense for when we're talking about the workforce and the job market and the job place. Right now, I'd say it doesn't matter what category you're looking in, academics, large health system, hybrid, whatever that is. For the most part, you're probably in the driver's seat unless you're going to a very saturated big city, and you have a very niche portion. So I'm going to just make up an example. You're a motility expert that wants to do esophageal motility, and you're going to New York City, then you might have some limitations there, right? Otherwise, the market's wide open. And so understand that when you're going into the interview, you're going to feel just like the interviews you did before as fellow, residency, they're interviewing you, I want to really get this thing, but you also have to interview them. And so put yourself in a position that you're asking the right question that you're not going to have regrets later around the decision that you made. So prepare for the interview to know who they are. Obviously, we all have access to the internet, understand who they are, know kind of what some of the things they may ask of you, but also be prepared to be open and ask them a lot of questions, because you're never asking my personal opinion. It's nice, the interview process, when you're looking for a job, you're actually, you know, in most situations, wined and dined, they pay for your travel, they pay for your hotel, because you're used to interviewing for training, when you're the one paying for all these expenses, you're sleeping on friends couches to save money. So it's really an interesting change, which just kind of goes to what we were saying before, where they are recruiting you, they, you know, they want you to be there as much as you're kind of looking into them, they're looking into you and vice versa. So it's just a very different dynamic. All right, I think we are ready to talk about the next questions. Should interview be phone versus in person, single, multi-day interview, or who is important to meet during the interview process? I think, you know, in the in the current world of post COVID and Zoom, it's probably much more normal now to have at least some portion of your interview process be tele tele by some sort of telephone or virtual. I would say in person probably is still going to happen as you move forward through the process. I think that's going to be important on both ends, both for the potential employer and for you looking for the job to see the facility meet the people there in person. But I wouldn't be surprised if some portion of the preliminary process is done virtually. And as far as single or multi-day, I don't think there's a exact right answer for this. It'll depend on how large the group you're interviewing with is, how involved it is. But similarly, they, like we kind of touched on earlier, when you're being interviewed for a place, they will work around your schedule. So if you tell them, I have these two days available, they will almost always make it work around your schedule. So it's different than fellowship interviews where they'll tell you, here's the day, good luck, see you there or not. If you're able to tailor your interview somewhat, and you do go in person, which, you know, obviously some of your initial interviews should be virtual, but definitely try to go in person for if you're seriously considering going to the place. Because you want to see if you're able to, it would be good to ask if you can actually spend some time in the unit, see how it operates, kind of get a sense for the culture of the unit, because as endoscopists, we're going to be spending a lot of time there. And just, if you can meet people that would be your schedulers, staff that you would work with, people that would be your peers, people you would work with in endoscopy, just try to get a sense of what your life would be there. Definitely, you know, definitely get a sense of the, I don't know if we put this in there, but, you know, get a sense of the town, make sure you can drive around whatever town. Some people do kind of tours of real estate with realtors, so to get a sense of the housing and market. If you have children, you might want to see some schools or get a sense of what the schools are like. Obviously, those will be kind of as you're making your decision and ready to sign with a location, but those are all things you want to look into too. I think the next few questions we can answer maybe together, we are kind of interlinked. So, Dr. Kostrom, Dr. Sharm already mentioned about travel expenses thing, so should I expect my travel expenses to be paid for, or should I dress, and should I communicate after the interview? I realize the irony that I'm wearing scrubs right now, but you definitely want to dress for your interview. Even if you're interviewing at your own institution, say you're staying on as faculty, or you know the person you're interviewing with, you really want to get the sense across that you're being professional, you're taking it seriously. So, I would encourage you to have, you know, business dress, even if you're just observing in the unit, or you're going to dinner with them. You certainly want to be as professional as you can be. And what are your thoughts about the communication after the interview for the job? Yeah, definitely. A phone would be better. Most likely you'll have these people's cell phone contacts. Definitely communicate in email, especially if you're seriously interested in the job. You don't want the job to not know if you're interested or not, because then they're going to start looking for other candidates. So you really want to communicate your interest, especially if you're interviewing in person and you're interested in the job. Certainly, you don't want to sign without really doing some thinking, comparing to other places. I think these places know that you're looking at other opportunities as well, but if you're serious about them, you really want to make that known. Tell them you're serious about it when you see them in the interview. You don't want them to be not sure how you feel. So definitely communicate while you're there. Stay in close, frequent contact with them. You don't want to be ghosting the places that you're interviewing. You want to be honest with them, too. Don't feel like you have to commit to anything, but just be honest about your ongoing interests. Communicate, I would say, at least weekly with email or phone, just as you're deciding if this is a good fit for both of you. I would say, it's not necessarily brought up in these questions, but you should be very polite and courteous with everyone you interact. Pay attention. You might only be interviewing with a few of the faculty or a few of the practice leaders, but if you interact with the administrators, if you interact with the endoscopy nurses when you meet them, if you have lunch with their fellows or anything like that, just be in mind that everyone is part of the process. In a lot of places, they will go to their ancillary staff and administrative staff afterwards and ask if there was anything unusual about the person they interviewed. And if it turns out that you were very polite to all the faculty, but you were rude to the administrator, that's often a red flag to people. So definitely be on your best behavior. This is a job that you're interested in. You want, as Natalie said, you want to be professional, be courteous, and show your interest. So definitely with that. And then if you're communicating with people afterwards, I think one thing is definitely be mindful if there was an administrator who did a lot of the work setting up your travel arrangements and all those things, and be sure you thank that person as well. And when can someone expect an offer after the interview? Very, very much. It's wide open. Sometimes I've seen people get a job offer at the interview. And then, you know, sometimes there's a series of candidates they have to interview. So I think there's like kind of a wide range for that. But certainly if you've not heard back in a timeframe that is important to you, so maybe a week or two, then it's reasonable to email back and just ask, just say, hey, I'm still interested and kind of where are you with the search. Yeah, definitely. And I think what I would say, what I would add to it is, where I'm interpreting this question is, you should continue your job search until you have an offer that you're happy with. So if you interviewed a place and you thought it went well, and you're waiting for an offer, I would not stop looking for other jobs until you have the offer in hand and you feel comfortable with it. You should just assume that it's not your job yet. Yeah, that's so true. Even if you're negotiating, you're kind of drafting contracts back and forth. It is not official until it's official. So definitely, you know, keep your options open. Be honest with them. But, you know, don't go telling your employer that you're, you know, starting somewhere if you haven't actually, you know, officially signed yet. Okay, here comes the most important thing, the negotiation. So what should you try to negotiate in your first contract? I think it goes back to your priority list. So I will tell you just specifics to me. So I knew I needed time to do research and that meant time to have prospective and retrospective research. I knew I wanted to make sure that at that point, I was brought in to develop an interventional endoscopy program in Indiana. So for me, I knew that the first of all, the equipment that they had on hand was important, but that I wanted to have certain milestones that would be achieved by the team that I hope to grow, which ended up becoming four interventional endoscopists. So those are things that are important to me. It goes back to kind of the original point that Dennis and Natalie also brought up, is kind of know your priority list. And then those are the things that you're going to negotiate for harder. So, you know, if your work-life balance is really important to you, you might want a little more time off, like it'd be PDO time. Or, you know, you want to negotiate down to a four-day workweek or whatever that is. If it ends up being that economics, then you want to negotiate more on the economic front. Hey, you want to push the salary a little bit or have a different bonusing structure. For me, it was, again, program building and being able to have a plan. And also then eventually get some research support. I want to research coordinators. So those are things that were important to me, but I knew kind of my priority list and I pushed for those. Recognize I might give on something else. I'm curious to hear what the others had to say. Yeah, I think being an interventionist, one of the things I ended up negotiating was fluoro time because if they tell you, you know, what you're going to do, you're going to have a lot of time to think about what you're going to do. And so, you know, if you're going to have a lot of time to think about what you're going to do, you're going to have a lot of time to think about what you're going to do. Yeah, I would say in general, my sense is that in academics, for example, there are things that they will not or at least say they won't negotiate like non-competes. Just a lot of the stuff that's standard in the document, there's probably a little more flexibility if you're starting a job that's not in academics, but certainly like admin time, call schedule, bonus, etc. can probably be negotiated. It's a little harder to negotiate for your first contract. I found that when I changed jobs, it's a little harder to negotiate for your first contract. I found that when I changed jobs, it's a little easier to negotiate in my second, I think, just because you're farther along in your career. But certainly if something's important to you, try to negotiate for that and that when you're making your decision in jobs is going to be another piece that you're going to use in making your decision, kind of what you're able to negotiate and how that aligns with what your values are. Yeah, I think the reality is there's, you know, a million things that you can bring up and it all comes down to what things are important for you and how much you want to push for various things. As you know, Neil and Natalie talked about how you want your time set up, how much protected stuff you want or funding and resources for whether it's research, if you want protected time for teaching or education, if you want protected time for this or that. I think the thing to be aware of is, if you think to ask for it, then ask for it. If it's important to you in any way, you should ask for it. Because if you don't ask for it, no one's going to know to give it to you. And realistically, the worst they're going to say is, no, we can't do that. If a place is really interested in having you and you ask for something, they're not going to suddenly rescind their offer because you asked, they'll just tell you, no, we can't do that or we can't. Yeah. So what is letter of intent and what is an appropriate salary offer and sign on bonus? Can you please talk about that as well? Only because of this administrative role that I just left at Indiana would I have any idea of any of this. I'm just going to be honest with you. Some of it I've learned because they made me take business classes and so on. But letter of intent is not binding. So you can sign five letter of intent. It doesn't mean anything at all. So don't feel cornered into that. The letter of intent, essentially, they're highlighting what would be a principle, in principle, key point agreement. So what they might do in a letter of intent to say, hey, we intend to hire you as a full time 1.0 FTE of which we're going to give you 30 weeks PTO and we're going to give you CME activity time for five days and $5,000 a year. It's just like the highlights, right? You can sign it. You can go back and fight it, push it back. You can walk away from it. It doesn't mean anything in terms of a binding situation. As far as getting a lawyer or some of those things for a letter of intent, I don't think it's necessary. But when it comes down to the salary, then you may want to get a lawyer or use one of the online kind of cheaper lawyer options that are $400 or $500. I think it's relevant to this in the last point is, if you're going in and you want to negotiate, understand who you're negotiating against. So if you're going into like a Kaiser, and it's a very standardized system, the amount of flexibility that you're going to have is going to be less. If you're going into a private practice that's more person group, you might have more. And then also knowing the need, right? So if you're going into a place, you're the only interventional endoscopist in 200 miles, you're going to be able to negotiate a lot more. You should be aware of that and don't be afraid to ask it. If you're going to be another interventional endoscopist in a city of like seven interventional endoscopy programs, you might want to be cognizant that you probably can't ask for the moon as much, right? And so these are just things that relate back to what's an appropriate salary offer because it's really in context. So I'm going to go a little different perspective with the letter intent. I actually didn't know what it was until I almost accidentally signed one. And then the guy kind of helpfully told me that it's legally non-binding, but I think there's some institutions where it's considered like a good faith, like we're moving forward, we can both back out, but these are the kind of higher level things that we're agreeing on. So I actually did have to negotiate my salary and bonus prior to signing it because I was advised that at that particular institution, if I were to sign it and then try to negotiate that later, that would be kind of a taboo and they would want to kind of pull out. So I would try, you know, you're not going to, it's not going to be legally binding and you're not going to negotiate for as detailed as in your contract, but I would try to kind of get things changed on it because it is a little harder in some institutions to change later. For my first contract, I did not get a lawyer because it was about three pages long. It was very straightforward. I understood a lot of it. For my second one, it was 40 and I did not understand any of it. There was so much legalese. It was so confusing. I got a lawyer basically just to explain to me what I was signing. And in the end, I couldn't change a lot of it either. We kind of made suggestions. The hospital said, this is standard. We're not changing it. But to me, it was worth it the second time just to understand what it was even saying. It was a very long contract. So if you are going to get a lawyer, I had a healthcare contract lawyer. It was a set price. When the hospital came back with their first round of edits, it was pretty clear they weren't going to change anything. And of course, my lawyer wanted to keep going with it because he bills by the hour. So at that point, I was like, you know, thank you for helping to interpret this contract, but I am, I'm done. So I did find it helpful the second time around, but not, I did not use it the first time. Dennis, did you have a, an LOI at all? Yeah, I did. I also think I was similar to you Natalie, where I didn't at the time really understand that there's been the letter, the LOI and the actual contract. But to be fair, I was just thinking in my mind, this LOI that I'm signing is more or less the framework that I wanted. So I had kind of negotiated the things that I wanted by that time. So I agree with the mindset of, while it's not binding, just go ahead and make sure the big piece frameworks are in there. You know, those are the things that I wanted. So minutiae, you can always negotiate later, but yes, like big things like salary, what your effort is going to go into those, those big things. You should try to have it kind of set. So there was a question in the Q&A. I think we have the next question. Are non-compete negotiable? And what can you negotiate for that? Non-compete is a very big thing in the media now because there was just that kind of legal case, but it's questionable about whether it'll actually be applicable to nonprofits and it's kind of being challenged. So I think the general sense I've gotten from the blogs about it is if there's a non-compete, don't assume that it's going to be overturned, kind of assume that it'll be kind of stand in court, at least for now. Hopefully one day there won't be non-competes, but at least for now. I have never successfully negotiated one. I don't know if anyone has, but one thing you want to pay attention to is if it says non-compete, is it just for the specific hospital that you're in or is it any hospital within the health system? Because if it's within a certain mile of any hospital within the health system, and it's a major health system, you're talking about a very, very large location. So just be mindful of that. Yes, Natalie's definitely right about that. And like, as you said, the language of, is it just places you go to or that any place anyone in the group goes to, you should also figure out if it's going to expand in the future. If the hospital acquires new institutions, are those going to be blanketed into your existing non-compete and things like that? But yeah, I argued pretty hard against my non-compete for this current job that I'm at, and was told that because of some situation that had happened shortly before I took this job that the institution was standing firm and that if I didn't want the non-compete, they would not hire me. So I've also not successfully gotten rid of one, but yeah, but you can always ask. Have you been successful, Neil, getting rid of any? I think, you know, sometimes you got to know the institution. So some institutions will really pursue them, University of Chicago. And so some will not necessarily pursue them as hard. I've kind of like, you know, I think one thing is, it depends on how specialized you are, but you can kind of push back depending on your specialty zone. So like, I guess it's fair to say, like, I mean, you know, doing ESD and doing high volume of ESD and coming into a state where there's not a lot of ESD going on, I was able to kind of leverage that a little bit in a meaningful way. But, you know, only to a certain degree. And I think Dr. Cosgrove already mentioned about the lawyer thing. Maybe someone else can talk about that. Should I get a lawyer advising me for the contract? And just to save time, I would just do two questions at a time. So what resources I should be asking for my first job as well? If someone can make touch base on this. I think, again, this comes down to what's important to you. But these are definitely things to ask about, you know, ask if you have a dedicated nurse, MA, admin, scheduler, or if you share it amongst how many people. So your ancillary staff support, you should ask about it. And you can certainly ask to have more or less of it, depending on what's important to you and similar research funding, equipment, protected time, all of these things. I guess the one thing I will kind of say about this, if you're going to go into an academic job and you're going to ask for protected time to do research, I would strongly advise you during that process when you're asking to outline a plan of what you are going to use that time for. If you come down and say, I want 30% protected time and you want, you know, $75,000 set aside for research funding, and then they ask you, well, what are you going to use it on? You don't have an answer. And they're going to say no. But so make sure you know what you're asking to do, what you're going to do with that time that you're asking to be protected. Okay. So next question is, should I ask for a guaranteed salary for a set time period? And also what elements should I make sure my contract has, like tail insurance or time to give notice and these things? I think as you're starting out, especially your first job, you should make sure that you have a guaranteed salary, at least I would say for the first two years, because you're going to be slowly kind of building up. You're still going to be, you know, when you graduate, you're going to be fully capable of being on your own. But you're going to be kind of learning the system, learning how to be in attending, learning how to, you know, answer patient phone calls and pathology and getting into a new groove. And with that, you'll be kind of slowly increasing your volume. So, you know, and if you kind of go out on your own or in your smaller practice, you'll be building your referrals and kind of going out and trying to get referrals or building a program. So definitely make sure that you have a guaranteed salary for, I would say, at least two years. And then tail insurance, very important component. Time to give notice. I also was not able to negotiate that in a lot of contracts, but make sure you're aware of how much time you'd have to give notice and that that language is clearly stated in your contract. Yeah, in terms of the protected time. So what do you think is an appropriate protected time? I would try to never have a half day. Like if you can have one day, one day a week, I think is ideal. If you can only have half a day, maybe do one day every other week, because to me, a half day quickly gets eaten up with just like if you have a half day. I had a half day of admin and half day procedures and I was getting called during the admin time to consent patients or ask questions about procedures that were done in endoscopy, ready to go. It will eat into your time. So I would try to have a full dedicated day, even if that's less frequent versus a half day. Yeah, I agree. Large blocks of time are better. One of my very good friends took a private practice job and he was in a situation where he didn't have flexibility to negotiate because of his family situation and his admin time. Basically, he was told that they didn't have a scheduled lunch break. So his admin time was basically an hour each day as his lunch break. Which he essentially said was useless because it was basically time to eat lunch, I suppose, and get set up for the next procedure. Yeah, I think that's a good point about the work-life balance comment that Neil brought up earlier, and also kind of moving from the fellowship training mindset to the rest of your life mindset. You might be in a fellowship where you're just go, go, go all the time, but to maintain that for the rest of your life would be a little exhausting. So definitely make sure you have breaks and admin time and ergonomically, too. You want to make sure you're not doing procedures, you know, 20 hours a day every single day. Because you have the whole rest of your career to think about. Yeah, I think it's sometimes hard to look ahead like that. You know, now, as you bring that up, I really think about that a lot. Like only recently, now I've gotten down in the pipeline a little bit, do I have an understanding of, you know, how to balance these things, right? And your life will change, right? Like when you're a fellow, you might be really zoned into what it is that you're doing, but the life around you changes and your priorities will grow or change in probably a good way as you mature. So just be prepared. And I think protected time is golden. You know, I've moved from a situation where I had a lot of it to maybe less right now. And yet I'm still trying to maintain all the things that I do relevant to teaching, research, and so on. It's hard to do that. And I think the point around the salary guarantee that Natalie made is outstanding. You know, when you go to a situation where production is the driver, that's okay. And it could be your benefit if economically that's really what your goal is. But if you're trying to do some of these other things, and not say that you need to, but if you are, those other things become hard if you're on an economic cycle that you need to be producing a certain amount. And just be aware that academia has changed, right? So we saw that, I mean, a lot of people have RV bonuses, or they've lowered the amount of academic salary time, or there are, I know multiple institutions I have friends at, there are traditional academic institutions where there's production as a big component. To kind of actually talk about this guaranteed salary a little bit, on an academic side, there's two models that you may come across. One model is that you will have a guaranteed salary, and they will tell you, by the way, if you exceed some productivity goal by chance during this protected time, you'll still get a bonus, whether it's based on your productivity or whether it's some sort of fixed bonus, or the places may just tell you here is a fixed bonus that we're gonna give you these first two years so you don't need to stress about it. But there'll be places that, again, will reward you for clinical productivity during that guaranteed salary time. And there are other places that will tell you here's your fixed salary and here it is, period. And the way they will tell it to you is that they want you to spend those first two years or whatever that guaranteed set time is to focus on building your practice and building your career into what you need it to be. Because if you are fixated on getting RVUs and doing an extra EG and colonoscopy at every opportunity, maybe you will not set up the program that you were hired to build. If you were there to build a motility program or if you're there to start the IBD program, they may want you to not worry about generating RVUs in those first two years so you focus on building that program. And so this is something that you should also consider when you're looking, if you're looking at an academic job, how your time is kind of protected and how the institution views that. That's a good point, actually. So the next step is the DCN. So what resources can help us in making our DCN and how do we ultimately choose? I think we have already like touched base on that a little bit before, but just maybe we can discuss more. I think there are some, as far as like deciding, obviously, you have your list of priorities, you're gonna have your family, friends that know you best, your mentors, although kind of as we mentioned before, make sure that they're telling you the best for you and not something that they kind of view, like if research is important to them, they're gonna give you skewed advice when they're giving it to you to choose a place more research heavy, for example, but you wanna make sure you're staying true to your authentic self. As part of, as far as kind of deciding kind of what's fair financially, there are certain books. Do you guys know Dennis and Neil? I forget the book that lists kind of the average median salaries for GI in the different geographic locations. There's like a name for it. And then Glassdoor also kind of publishes some salaries. So I feel like that's a helpful way to gauge that it's a fair salary that you're being offered. You know, I think there's a whole lot of different ways. It depends on what your system uses or whatever the area is. But I think that what Natalie points out is important, like you should do your research. So you can look at MGMA salaries, you can look at AGMA, which actually looks more academic salaries. You can use a blend. There's another survey called Sullivan-Cotter. So all those things are there. I happen to know way too much about this because I had to create those contracts for the physicians that I mentioned earlier. So I kind of had an idea of that. I think those are all available. Some you have to pay for like MGMA and so on, but there's backends to like not have to pay for that. And then really nice resource is called Resolve. Just the word resolve, you look it up. It's actually a firm that's for physicians of all specialties, and they will hook you up with a lawyer. They'll give you all the open job opportunities. If you look up a location, you have to pay a little bit for that. But I know multiple people across the board that just recently started to use that. They can be helpful and they will give you comparative job salaries and give you access to MGMA and all that other stuff too. But definitely do your homework, right? I mean, because you want to know what the marketplace is. Okay, so at what point in our search should we commit to the job offer and what are some red flags we should look for? Dennis, what did you commit? How did you decide? Well, for my first job, after I waited, it essentially kind of came down to going back to the original, like when I was looking for the job and making my priority list and figure out what was important and kind of came back, settled down, looked through it. And for me, at least it was relatively clear from my options, which job I felt was the best job to start my career. And so once I was done, I actually, I think if I remember correctly, they reached out and told me that they were interested in hiring me before I kind of told them they were my top choice. So once they offered me the job, I was pretty quick to just say, yes, I'm on board. And then we started the negotiation process. It was like the biggest thing for you, was it location? Was it the fact that this academic opportunity let you have the balance of what you wanted? Did you have the balance of what you wanted to do with your career? Was it the other faculty? What were the things that were like, yeah, I know that this is the one. Yeah, for me with this first job, I was not too geographically concerned. I was pretty flexible with that. And so for me, I was looking for kind of what I thought was kind of the best academic career opportunity that kind of fit with my interests. And so as far as, you know, obviously being an international endoscopist, looking at a place that had volume and had complexity, had teaching opportunities. So I focused mostly on the job itself and was willing to overlook some of the ancillary stuff for that first one and figure out from there. Now I was waiting for you to say the people, Dennis. I was waiting for you to say that. Dennis came to watch you when I was there. So I was waiting for him to say. I won't take it personally. Yeah, for me, I was looking at a combination of, my brother was in the area, so I had family support. That was important to me. I wanted to stay in academics and be in a nice supportive environment. And I wanted to be in a bigger city and with a major airport so I could travel because I still wanted to travel. So there were a lot of different job and non-job factors that came into play. As far as the red flags, some places are very overt with their red flags. So I would really pay attention to that. If you go on an interview and somebody is saying, like, do not come here, it's a very toxic place, take that seriously. Don't think, oh, well, but the other person is very nice. I would take that very seriously. If you have any red flags, definitely take that into account when you're making your decision. I think a good thing to look at, whether it's academics or a private practice job is when you're thinking of red flags is look to the amount of turnover the group has had in recent years. And if possible, try to reach out to some of those people that have left and ask them why they left. And hopefully they'll be honest with you. I can say that after I left my job at Wash U to come to University of Chicago, there were several people who interviewed for the Wash U job. And I think at least three or four people reached out to me to ask me why I left, trying to pick up if there was any red flags at the job. So I think that's part of doing your due diligence and homework. If you see that people have left, especially people that are early in the career or only there for a short time, it's, I think, important to figure out, if you can, what their story was. Yeah, I did that too when I was looking. And some people say, oh, family reasons, and then you don't have to worry as much. So I think that's smart. I'd say, don't look at who's there and look at who left. That's like a golden rule for this thing that I've learned and heard and seen people falter around. It always looks like there's massive opportunity, but you gotta look at, say, look, how come there's seven open positions or there was a turnover of three people over the past one. That's a lot, right? And we try to overlook that sometimes. So definitely, anytime you're looking at a job, even if it looks great, look at who's there and look at who's left. Anytime you're looking at a job, even if it looks great, look at who left and try to contact them. We're all one community, right? So I think doctors will be very honest to another doctor if it's a one-on-one, which is helpful, right? We should look out for each other. Great point. Yeah, that's a great point. Okay, preparing for your first job. So how should we start preparation for our first job? And should we take some time off between graduation and starting the job? I want to bring up one point, I guess, because none of us are in any sort of small private practice group setting. We don't have, I guess, a whole lot of experience to speak on this, but I'm going to bring this up because I think it's important. It happened to another one of my friends who took a job. If you're looking at a smaller group, one of the things that I've been told is important to look at is to get a sense of the age of the group and figure out, like, if you are joining a group of five and the four people are all very senior in their 50s, you might be trying to think about what's going to happen if this group gets an opportunity to sell to private equity or get bought out and get acquired by a hospital. And are you going to be left kind of holding the bag when they leave if you haven't made partner yet? Or are they going to all try to stop taking call because they may have a clause in their contract that they ask you to call at a certain time? So if you're looking for a private group, look for the age distribution. And ideally, you want to have a good distribution across career stages. You don't want to be the only young person in a very old group, for example. Yeah, that's a great point. For the taking time off, I definitely would recommend it. I remember thinking like, oh, financially, taking a month off, I won't be making any money. But you're going to make money. Hopefully, if you negotiate for a good salary, the financial difference between fellowship and attending is going to be very big. So you won't really care about the month or two salary loss. It's kind of a whirlwind getting ready for your new job, moving, if you're moving to a new place, getting licensing. A lot of people spend the time to travel, get married, start, you know, move their kids into school, et cetera. So I would really encourage you to take maybe a month or two, I would say about two between fellowship and starting your first job. Yeah, take more time. I regret it. I went straight through like all of it, like undergrad, med school, residency, fellowship, interventional, straight to work. And it was like, I don't think I took more than two, three weeks off. I regret that. And even between this last move that I just did, I would say the more time, the better. What Natalie said is like, yeah, 100% true. You won't miss the money. Yeah, I think I completely agree with these two. As long as your financial situation is one where you can manage to get through that. And obviously everyone's situation is different. But if you can manage it, absolutely take the time off. You will never have these kinds of opportunities to take extended time off like that with no responsibilities again. I remember I was at Northwestern for my advanced year. And after I did the job, one day the division chief, John Panolfino came in and was just chatting with me. And he asked me how much time I was taking before I started. And I told him, I think I took eight weeks. And he laughed and he said, do you know how much money I would pay to have eight weeks off with no responsibilities? Because he's at a stage of his career where even if he's on vacation, he has societal responsibilities, committee responsibilities. He's like, I will never be left alone until I retire or maybe die. And so I took that part. I was like, I'm glad I'm taking this time off. Fortunately, COVID interrupted my time off. And so that was a whole nother thing. But definitely take the time off if you can manage it. So when relocating, what resources can help us with this? And if we are moving to a new location, should we rent or buy? I'm gonna jump in and answer the last one, actually, if that's okay since we're running out of time. This is one of the things I think is like the most important takeaway of anyone watching this. Get your own disability insurance, for sure. You are a proceduralist, presumably doing gastroenterology. If you have any musculoskeletal injury and we are high risk for that, and you lose the ability to scope, oftentimes your employer will offer disability insurance, but it's capped at a certain amount. It's taxed. There's all these contingencies. Like in most cases, they'll say, well, yeah, you can't use your hands anymore, but you could go work for an insurance company, answering rheumatology questions. Technically, you're a doctor. So you really want own occupation, disability insurance. I would get it now. So before you have any pre-existing conditions, you'll carry that policy with you wherever you go. And then God forbid anything happens, you protect your ability to really have an income and kind of ensure basically all the training that you've done up to this point. Yeah. Disability insurance is an absolute, I would say for everybody. It's also, it's cheaper to get it while you're young. It's cheaper to get it while you're still in training. And then, you know, kind of what Natalie was saying. So since everyone here is a GI, is GI, when you're doing disability insurance for proceduralists, there is a rider on your disability insurance that specifically is a clause that says, if you are disabled and can no longer perform procedures, but can still see clinic patients, that situation she alluded to, there's a rider that you can add to your disability insurance where you will be paid your full salary or your full disability insurance payout if you no longer can perform procedures. And that's an important rider to consider. That's probably important to a lot of you because that covers that scenario where if you break your arm or something happens and you can't scope and you can still see clinic patients, you will still be covered fully with disability. And then even if you're up for it, you can still work and do the clinical stuff on the side. Yeah. Just make sure you know what company you're getting, get it as a fellow and make sure that it's specific. So it puts in things like hands, back, legs. So I've had one since I was a GI fellow. So the policy ends up being less for you and it also covers you a little better because you've been longer with the company. And there's strong companies. I mean, Standard and Guardian are two that stand out. There's more than those, but you want to not take like a flimsy company. You want a really solid company because it's going to pay dividends later on. So those are two that jump off the top of my head that are companies that I know people use and have had to rely on. Yeah. I have Principal. It's not as good as Guardian, but it was a little cheaper. But it still has, I still put all the own occupation clauses. There's riders you should look into if you have the time and opportunity to research it. There's also reps that you can ask questions to that are familiar with the riders, but you want kind of future benefit, increased rider, partial disability rider, own occupation. So definitely look into that now before you start your job. Okay. So now starting the job. So in the interest of time, I think we should just sum up the questions, multiple questions at the same time. So how can I make a name for myself and how can I establish a niche and finding a mentor and the resources? I think the first question is funny. Like make a name for yourself. I think it depends on how you define that and what that means, whether that's a clinician or research or whatever that is. And why is it important to you and how you define it? How you define that? I think some of the others we kind of answered, right? In terms of a niche is, you know, self-defined as Natalie had pointed out, having other people who are successful in the, what you're trying to do, as Dennis pointed out, but his job search and resources are relevant to the discussion that you have initially when you debate and you have your priority list, which you debate upon what you want. And then one of the last questions. I think a lot of these are kind of tailored towards more of an academic job side of things. Although I guess it's important to, you know, establish yourself in practice and do, it's a different world, I suppose, of kind of making yourself, almost marketing yourself to referring doctors that you have business to do. But from an academic standpoint, I think one of the things is be very professional, be very collegial, be available for people. You know, when you're, when referring doctors contact you with questions, answer them, be polite, see their patients. And obviously your work hopefully will stand for itself. For the last question, you know, what if I don't know everything? What if I need help? Hopefully you found a job in a group where you feel that you have the support to get the help. And I would say, hopefully you found a job where you also do not feel scared to ask for help. See, this is my opportunity to make up for my non-answer earlier, Natalie, because one of the big things about my first job at WashU was knowing that there was a really strong, established group and a lot of support, and that, you know, there were three advanced endoscopists at any given day in the endoscopy unit. So if I got into trouble and I needed help, there was always someone right around the corner to help, and that it was a group that was very willing to come help. Because you will need it at various points, not just your first year, but you will continue to need it. I still need help every now and then. Yeah, lifelong learning, lifelong questioning. Yeah. I don't know if we should mistake some of the online questions as we go, but there've been a couple that are just popped up and you're going from top to bottom. One was, is there any specific setting, academic versus private versus other, that you think is better as a first job? Yeah, so this is a slide that we put together for you guys relevant to, you know, what is traditionally academics, right? And so this world has become a bit more blurred. On both sides, large health systems are having fellowships, training environments, as you guys are seeing, that are not traditionally connected to a university. And vice versa, we're seeing universities that bleed into the community where they're absorbing community practices and having kind of a blend in certain states, right? And so academics, I think most of us, all three of us, I guess, are involved online, relevant to this is, you know, there's some component potentially of research, teaching and, or both. And we've kind of listed out what that research can look like. It could be retrospective work, it could be prospective work, it could be analytics or quality-based work that you want to look at, or it could be even bench and translational. And then teaching, there's a myriad of teaching opportunities from fellows, advanced fellows, residents, medical students, and so on. And I guess it's just important to understand that the world seems to be rapidly changing. And, you know, we point out some large health systems that have full-on medical schools and fellowships. You can see there, Kaiser, Geisinger, Allegheny, Aurora, Advocate, that were not because they're traditional, at least what we think is a university-based academic program. And then same thing, there are large private groups that also offer these opportunities. So I don't want us, the three of us being not necessarily involved in that category in the past, or having experience, those are also possibilities where you're going to have some components potentially of research and, or teaching. And we listed some of these, what we call supergroups relevant to that. Just thoughts maybe from Dennis and Natalie around this definition of academia and, or maybe emphasizing what points research or teaching-wise people should be just aware of. Yeah, I think having gone from academics to hybrid, it seems like the lines, the differentiation is definitely changing. And currently I'm in a hybrid group in a more kind of private hospital system, and it's slowly becoming more academic. We have, you know, med students, residents, fellows. So I think there's definitely differences with the hospital system. We don't have a major academic institution. There's not a lot of like, you know, bench research, clinical research being done, but certainly the differences are blurring a little bit. So that goes back to, I guess, that question. Is there any specific setting, academic versus private versus other you think is better as the first job? I think we probably all three of us would answer very similarly because our priorities might be. So at least in our clinical interests and so on, but it probably does go back to what you're trying to achieve. You know, if you don't want to go to a place because it has a nice academic name, and then your real core interest is to do a lot of volume as a clinician, maybe, and maybe you do, and it's aligned to that. You just need to make sure you understand, is it aligned to the values of that institution and what they're prioritizing and what their culture is about? And does that line up to what you want to do? It's not a right or wrong answer. It's just, again, knowing yourself and then picking something that lines up to what your values are. Natalie kind of has already set us up for this slide really, really well. And then just overlaying the question, we can go through this slide, but I think for the both of you, so the next question was, what's the average take-home salary after taxes? And then how many years on average do you stay at your first job? So here we've shown you all the jobs on the slide, but what are your guys' thoughts to those couple of questions? As far as how many years you stay at the first job, I think it really depends how good the job is a fit for you. The first year or so is going to be an adjustment, so I would kind of hold your decision about the job for at least the first year until you really get comfortable with the system. If it's not the type of job that you like, it's not working for you, then I would start looking for a new job. Don't feel like you have to stay there, you know, forever. If the job is working for you, and you're really developing a niche, and you're really growing kind of personally and academically there, then you can stay, you know, as long as you want. Yeah, I think what Natalie said is very true. Your first job can be a stepping stone job, but if you find a good job, it can be your permanent forever job, or it can be a job you're at for decades before you leave. And I think, you know, I was at my first job for a year and a half before I left, but I left for family reasons, the long distance relationship that needed to not be long distance anymore, not because of any issues with the job. So I guess my stress on it was actually the opposite end of trying to figure out, oh, how's this going to look if I'm switching jobs this early? But as Natalie said, I think one of the challenges is if you take that first job, and after a year, two years, you find yourself disillusioned with things that are not going well, because I think then there's a very stressful and challenging question of, well, do I leave this job and go into a new job, hoping that it's better? Or do I tough it out and hope that something here can be improved? Or that maybe just if you endure it long enough, you'll get used to it? That's a very challenging question to answer. And I don't think there's a right or wrong answer. But if you know yourself, and you know that you're not happy, there are some fundamental things about the job that don't work for you, I would say, be careful not to be anchored to that job by inertia, and be open to the opportunity of exploring other opportunities. And honestly, looking for the second job after you have the first job, I think in many ways is easier. Because you have that job, you don't need to tell your employer necessarily that you're looking for a new job until you're fairly far along the process. And so unlike now, when you guys are fellows, and there's a very clear deadline, like you are going to end fellowship June of whatever year you graduate, and you're not going to have anything to do but get a job after that. So there's a clear deadline, you need to have a job within a certain time frame. But if you already have an existing job, even if it's one you don't love, you have that backup option that that job is still there while you're searching for your better option. So one of the questions that goes along with what you just said, Dennis is, and I get to ask this a lot, and I've seen some of our fellows do it, but once a fellow, always a fellow, what are your thoughts on staying as an attending at your fellowship institution and working with your mentors and attending as co-workers? That's a great question. I didn't do that. I've talked to people who have that experience. I'm going to defer to Natalie, because I know she started off at WashU where she did her advanced year. So she can probably speak most eloquently on this. I don't know if it's eloquently, but I'll try. I liked it in a way. You know, I, in a way, it made the transition somewhat easier for me. It was somewhat harder because I did feel like I was still in least initially seen in the fellow role, but I knew the system, I knew the staff, I knew the environment already. It made it a more comfortable decision. So there's definitely pros or cons to staying at your current institution. And, you know, it's whatever, you know, if you make your pro-con list, and then all the pros kind of align with your current institution, don't feel like you have to go elsewhere. You can certainly, you know, earn respect in your own institution. So I certainly think, you know, whatever is best for you overall, even if it's staying at your own institution. Yeah, so I didn't stay. I was at UNC, and then I, you know, went back to went to Indiana to build out this program, but I had two of our former interventional fellows stay. And I think on the other side of it, you know, as somebody who was your fellow that joins you, you know, you need to understand the change, and then respect that. And then, you know, hopefully the people that you chose to stay for, they're there to really kind of push you forward, right? So they see you as somebody that they put a lot of time and energy into. And if that was the culture there, it can actually benefit you in that sense, because they're going to want you to do more. They're going to give you opportunities that maybe are on their plate, that they say, hey, I was asked to speak here, or I have this research opportunity, can I put your name on the paper, so on and so forth. So it just depends on some of that culture, I think, that you're at. And you would know that after three years, or four years there, that, or maybe one year if you're advanced there, is that the right culture there? Are they going to support you? So that, I base that decision. A little bit on the slide deck, so we tried to break down your traditional university, hospital, health system, and then private. And I think private, you know, it's a really, really wide category. I think Dennis alluded to this, it could be a small three, four, two-person group. It could be a massive private group, like AGA is a great example in Atlanta, where it's like an infinite number of physicians. So I think just take private with a grain of salt. But if we walk through like the university-based, you know, usually like Dennis mentions, a salary-based offer, it can vary and guarantee, it can vary on is there an RBU component or not, as it was mentioned before. But typically, it's not that, somebody asked this question online, so I'll answer it. You know, academic physicians might not make as much as private physicians on average salaries. And someone's asking, how do you look at that? You can look at AGMA, but you can also just ask. I think if you ask around privately, most people will give you at least a range of kind of what would be reasonable at an institution. And I think that's helpful. The pros and cons of all three of these slides, without me going through all of them, I think we tried to highlight some of them, but I don't know if there's any specific comments that Natalie or Faisal or Dennis have relevant to what's on the slides. I will say about the, sorry, go ahead, Natalie. No, no, go ahead, go ahead. I would say, I think about the salary thing. I think I saw this on Twitter a couple months ago, and they talked about that physicians, for whatever reason, are open about a lot of things with each other, but people are often a little bit secretive about their salaries for whatever reason. It seems to be a very personal thing. And that, I think, for better or for worse, since people aren't comfortable sharing, ends up being to the benefit of the employers. Because if no one knows what each other is making, then the employer can be shadier with what they're offering people. But I mean, it is just the reality of what's going on. I mean, academic salaries, I can tell you, it will still vary widely, and it may depend on the institution's perception of their own prestige, geographic location, things like that. And I can say that looking at academic salaries in my first job, and this was in 2020, so I guess we have a few years of inflation to adjust for, but the range of places I looked at ranged from about $225 to about $375 for academic salaries at that point. So there was a question in Q&A. So someone asked, what are the risks involved in joining a hospital system that used to rely on private group but now wants to have their own employed GI doctors? Yeah, I can answer that. So, you know, we just talked about this before, look at turnover, right? So it's not that every private, sometimes the private group's values don't align with the health system. That could be that. And I'm sure that's what the health system will always pitch. But probably do your research, right? Understand why was a private group not successful? Because typically, they're trying to do volume and take care of a lot of patients. So for whatever reason, if they weren't successful working with that hospital, there could be other things. And so I'd be leery of that. And know that if you have a private group that's been there for a long time, if you're doing general GI work, your work might be different than somebody who's IBD or interventional focused. So you may align more to a hospital with a certain subspecialized skill set. But if you're a generalist, you're going into an area, and then there's a private GI group that backed out, it's worthwhile asking them because to me, that's a bit of a warning sign if you're the exact same, you're expected to practice the exact same work. I think one thing relevant to that on the other side for private, this has become aware to me recently in trying to kind of build this multi-state thing that I'm involved with here in Colorado is just be aware of, you know, who's the owners of a practice? Do you have ownership into a practice if you're on the private side? If you're on a health system side, there are health systems that allow for some joint ownership of ASCs. You know, Indiana University is one, right? And so just be aware of that part, like the ownership component. I think people are more wise now about business and perhaps than when we came in before. I think it's just generation, you know, we're going up online and everybody's a bit of an entrepreneur to some sense. So understand your equity ownership. And then if it's private, you know, what's the private equity component of that? We've been really focused on kind of what our world, the three of us speaking looks like more on the health system academic side, but for the private side, which is going to be a lot of people probably watching this, you know, understand your private equity component versus your own single ownership component and how that breaks down and translates to your downstream economics and your work effort ratio, which means, you know, how much do you have to work to generate your salary versus passive income streams? One thing I will point out on the academic job side, and Neil and Natalie, you guys can correct me if I'm wrong about this, but one perk on the academic side that kind of a couple of the perks that make up for the lower salary. One is that generally speaking, your work-life balance will be better. Your call should be a lot easier because if you're an academic center and you're in a group of 30 faculty, then you are going to take call once every 30 nights, as opposed to if you are in a practice group of five people, you're taking call once every five nights. And then another big perk that happens at a lot of academic centers to try to make up for the salary difference is that usually the job benefits system is a lot better, whether that's just a better health dental insurance package that they have, better retirement packages options, or other ancillary things. So for example, at University of Chicago, I have kids, and one of the perks of University of Chicago is once you invest enough years in here, university will cover 75% of your kids' college tuition, which is a huge savings that you're probably not going to, you won't find that at every academic place either, but there are unique benefits that can be hidden in the academic world that kind of offsets some of the straight-up salary loss. Yeah, agreed. It goes back to your priorities. There's a lot of other things, and like Dennis mentioned, they can be really variable, right? So each institution, whether they're state and they have a university associated, or they're fully like federal, or for the VA as an example, there's just quite a bit of like other benefits that can come that might translate to benefits to your longitudinal welfare. I say the call thing is a big one, at least for me, like, you know, I came out doing only interventional call. I've never had to do general call, and so that was a big benefit to me. And so, you know, just thinking about the call structures in these academic institutions will be sometimes different and allow for a lot of sub-specialization. It looks like there's a question in the chat about RVUs. So I think this is probably one of the things that you can negotiate, your RVU target, having a guaranteed salary as you're building your practice is going to be helpful with that. Interventional, I imagine, actually has higher RVU targets because a lot of the like ERCP, stent placement, et cetera, might actually be a little higher RVU target than some of the general procedures. So that's something too, when you're asking about kind of the salary of the people, like if you're interviewing in a place and you try to get a sense of what salaries have been offered, try to get a sense of what RVU production is and has been. Like if there was a group that left, were they under their target? Were they, you know, over their target? So it's really important to try to get a sense for that, especially if you're in a production-based model. To kind of expand on that. So, you know, what Natalie was saying is that it's correct very much that ERCP generates more RVUs per procedure than EGD or colon. But in an academic world, I think a lot of times that balance out. And also in academic settings, a lot of times if you're hired as an advanced endoscopist, you will probably have more procedure days built into your schedule compared to the general GI folks who may be 50% clinic, 50% endoscopy, whereas you might be 75, 25. So that often offsets what's happening. But I do have colleagues who are in private practice where if a unit is run efficiently, the, that question is actually correct that someone can generate, can do 20, 25 colonoscopies in a day at an efficient private practice group. Whereas ERCPs, because of the complexity of them, you know, you may only be able to get through seven or eight of them. And so the colonoscopies will win out on the RVU target in that setting. And that's a tricky thing to negotiate. And it depends on, again, the setting that you're going into. Like Neil mentioned earlier, if you are going to be the only advanced endoscopist in this group in a hundred mile radius, you probably have a little more leeway to ask for protection if you're bringing the service to the group. But it's definitely a source of frustration that I've seen in our, our advanced fellow group texts from when we were applicants back in the day, because there are folks who are in private groups and say, Hey, listen, we do all these complex high risk cases and make it. So the group says that they offer the service, but my partners just crank out screening colon and they make $200,000 a year more than me. So it can be frustrating. And, you know, it's something to discuss when you're upfront talking about it, if you're an interventionalist. But I don't think there's an easy, correct answer. It's something you have to figure out with the group as you negotiate. Yeah, that's a good point, especially the newer interventional procedures for anyone that's thinking about interventional, a lot of them don't even have really assigned RVUs. So that's something you want to really think about if you're planning on doing a lot of those procedures. Yeah. So just relevant to that, I think it's really important and, you know, be thoughtful about either you're going to push for a higher salary, you're going to push for an RV and multiplier, or you're going to ask for ghost RVUs for things that, you know, I know I come up with every week, like a cheap home or an ESD, or if you're doing interventional US, right, there's a lot of interventional US procedures, like gastroparesis coiling, that we perform that you're just not going to have a work RV. So you have to figure out how you're going to make up for that. So there's what three really standardized ways to which you that you ask for just a fixed salary, or a component of a salary under a medical directorship. The other alternative is you ask for a higher work RVU amount, because some more of your work RVUs will be unaccounted for your you ask for a work RVU multiplier, which is the same kind of thing, or you create phantom work RVUs. And if you have an interest, I know I reached out to someone at NYU, who helped me set that up at my last position at ADM, and then I helped two other people and now it turned back around that we had some standards to pull when I moved to Colorado. So just whatever it is that you need to do, but make sure that you're able to do the work that you want to do and get some accreditation for it. And by the way, I think that will translate also to, you know, if you're a motility person, I imagine that'd be hard to I think we have three interventionalists on, or if you're doing IBD, like, I, you know, I don't know that world. But I would imagine that, you know, there's long conversations that are had for people on multi drug therapy, and so on things that would scare me that so just think of it the same way in whatever it is that you do. Yeah, that's a good point. And we're talking about resources. We've talked a lot about equipment, admin time, academic days, but think about your support to will you have a scheduler? Will you have a nurse if you're in clinic? Will you have APP support? Will you have APP support seeing consults on the weekend? So those are all things that you should ask about, too, and try to negotiate to relevant to the career transition thing, you know, like almost, I was reading this, like 50% of graduates will end up switching their first job within two years. That's across all specialties. I can't imagine you guys going to be too far off the standard curve. I think, at least when I got out, and my mentality was, you know, seven, eight years back, it was like, hey, you go to this job, you stay there. And I stayed my first place at nine years or eight years that I just moved, right. But I think people are changing a lot. So what do you guys see Dennis and Natalie, like a phase? Are you guys seeing a lot? I see a lot more people moving. Yeah, I think I moved, I moved within two years of starting that first job. And like I said, you know, we've, we've been hiring here. So we've interviewed people. So obviously, to name names, but we've interviewed, you know, junior faculty who are within the first two, three years at their job and are thinking about switching for various reasons. So I think there's there's a lot more potential movement of people considering movement than you might think, on your own. Yeah, and whenever the right the time is right for you, whether it's your family situation, you have a career interest change, you kind of don't jive with the culture in your current work environment. Two, as you get farther along in your career, there's kind of two ways to get promoted. One is to kind of negotiate with your own institution. And one is to go to another, go to another one or interviewed another one as a way to kind of get a promotion, get a new opportunity, whether it's a directorship, etc. So talking about career transitions, that's kind of one of the opportunities. Yeah, I think that blends right into this last slide that this the world is changing slide, you know, GI is a coveted field. So I think we mentioned this at the beginning, and it's nice that now that brings it back at the end to, you should know your value, you should know this highly specialized field as the most competitive field right now to get into out of control medicine, there's a massive demand and need and a shortage of GI physicians. And so, you know, use that to your advantage. And just at least feel your own know your own self worth. Sometimes it's hard when you come out of fellowship and understand your marketplace. Oh, you know, one thing about negotiation that I wanted to bring up. It's not always possible because of the timelines on it. But it's always good to have two offers. Because you can take what someone offered you. And you can take that and go to the other place and say, well, I have an offer with this, this and this. And then you also can see what different places are offering you and get a different sense of if someone is low volume, if someone should be giving you something if something's important to you. So again, the timelines won't always work out. But this is also why you know, we said, apply to multiple jobs, go on multiple interviews, don't stop just because you have one that you like, because if you have multiple interviews, or multiple job offers, you have more leverage when you're negotiating. Absolutely. A lot of comments around this was informative and helpful. I mean, I hope that's what this was. I don't know that we necessarily had these resources, always available to the fellows. So thankful that ASGE is putting this type of category and very practical topic out. Well, if there are no more questions, I will close things out. I want to thank our GI fellow moderator and our content experts for tonight's presentation. Before we close out, I want to let the audience know to check our upcoming ASGE educational events into register. Visit the ASGE website for the complete lineup of the 2024 ASGE events. Our next Endo Hangout session, Endoscopic Surveillance and Inflammatory Bowel Disease will take place on Thursday, June 6, from 7 to 8.30 p.m. Central Time. Registration is now open, so please register today. At the conclusion of this webinar, you will receive a short survey, and we would appreciate your feedback. Your experience with these learning events is important to ASGE, and we want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, ASGE training membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to become a member today. In closing, thank you again to our presenters for this excellent webinar, and thank you to our audience for making this session interactive. We hope this information has been useful to you, and with that, I will conclude our presentation. Please have a wonderful night.

GI fellows

first job

negotiating contracts

non-compete agreements

career goals

guaranteed salary

research time

work-life balance

resources

admin time

legal advice

contract reviews