Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Whether you are a Gen-Xer about to leave training or already in practice and considering a change in venue, establish a realistic set of essential work-life priorities before you negotiate with employers. Become familiar with the fiscal outlook, reimbursement models, staffing patterns, caseload, and coverage requirements. Communicate with other physicians who have recently been hired and keep your requests in line with the real or perceived norm for salary, benefits, and defined work time. Once you’ve established yourself as an indispensable member of the medical staff, it will be easier to attain your ideal work-life balance.
— John A. Fromson, MD*
Young physicians can — and increasingly do — ask for preferred schedules or other accommodations, but there’s a time and place and way to broach the subject
By Bonnie Darves
It’s understandable that physicians coming out of training want to find a practice opportunity that not only suits their clinical interests and skill sets but also offers the potential for a reasonable balance between work requirements and their personal and family life. It’s also understandable that the practices, hospitals, and health systems seeking to hire new graduates are eyeing balance as well. Ideally, they want candidates who are highly skilled and committed to providing good care and willing to help the organization meet its operational and financial requirements.
The issue — or challenge, in many cases, today — for employers is finding a way to structure and offer practice positions that meet their own and candidates’ needs. And that’s no small feat, in an environment where, particularly in primary care, demand for physicians far exceeds supply.
The recruiters who frequently find themselves in the middle of this equation report that they sometimes see a bit of a disconnect between the kinds of lifestyle accommodations and concessions physicians want and what the employing entities can reasonably offer. “What candidates ask in terms of schedule preferences or work week [structure] depends largely on whether there’s a shortage in their specialty,” said Chris Kashnig, a lead physician recruiter for Dean Medical Group in Madison, Wisconsin, part of SSM Health. “What I am seeing is that young physicians, in pediatrics, for example, want ‘bounded’ work — a strictly outpatient practice with a defined schedule. The problem is there aren’t enough of those positions around.” In primary care, he added, his organization is experiencing an increasing amount of requests for part-time positions, particularly from women and candidates with young children.
Some candidates these days, particularly in primary care, have no qualms about asking for special accommodations across the board, recruiters report. Here’s an example: Residents in internal medicine or family medicine asking for a fairly substantial list of work-life balance accommodations — a four-day work week with flex time, loan repayment, a signing bonus, and relocation expense coverage. And on top of that, by the way, they would also like top-dollar compensation and no call duty.
What’s wrong with that picture? For one thing, it doesn’t imply — or leave — much room for give and take. Secondly, such an exhaustive set of requirements doesn’t take into account the fact that the newly graduating physician is just that: a medical professional new to her or his career and the real-world practice environment, who’ll require significant training and a substantial investment on the part of the hiring organization. Further, accommodating a wish list that’s out of sync with what the organization’s other physicians receive, expect, or experience might be politically untenable and is not particularly conducive to supporting collegiality.
“Candidates need to be reasonable with their expectations, and realize that they’re going to be part of a team — that they’ll have to make some concessions,” said Patrice Streicher, a professional development coach and director of Vista Staffing Solutions’ search division in Wisconsin. “Yes, we can get you a four-day work, but you should be prepared to give and take. It’s also important, I think, for candidates to separate their needs vs. wants, before they talk to recruiters.”
Understanding practices’ needs
Another area of potential disconnect between graduates and hiring organizations is a limited understanding, on physicians’ part, of the constant balancing act that practices face: They must staff to guarantee adequate care coverage for patients while ensuring that they don’t pay more than they can afford for physician services. All recruiters interviewed for this article said that most young physicians they encounter have little understanding of the operational realities of managing practices, and staffing hospitals and health systems. And residents likely aren’t aware of the market realities and legal issues organizations contend with when they recruit.
That’s understandable, perhaps, because most residents have not been exposed to such business concepts and have been focused on clinical skill-building. Nonetheless, this lack of awareness is a likely contributing factor to unreasonable expectations, some recruiters pointed out.
“Most young physicians don’t have a clue about how staffing a practice works, so they don’t have a sense of what they can reasonably ask for and what practices can actually do,” said Regina Levison, vice president of client development for Jordan Search Consultants. “We’re constantly educating clients about this.” Ms. Levison said that the tenor of opportunity advertisements that detail the upsides but not the job requirements, fueled by the residency rumor mill, exacerbate the expectation disconnect. “When candidates hear that a colleague got a part-time primary care position that pays $250,000 and requires no call, they think they can ask for that too,” she said, pointing out that such positions are rare and likely won’t be in desirable urban areas.
“It would be helpful to all of us—residents and recruiters—if residency directors were a bit more in touch with the market and could share that information with young physicians,” said Bruce Guyant, regional director of physician recruitment for LifePoint Health’s western region. “I think that medical leadership needs to understand better what goes on in smaller communities and rural areas, from the business and market standpoint, because that’s where the bulk of the jobs and patients are.” Mr. Guyant noted that many of the rural hospital positions he recruits for offer high compensation and financial incentives, but can’t be highly flexible in the schedule arena.
The ‘Gen-X’ factor
It’s hard to pinpoint what is driving what appears to be a palpable shift in young physicians’ expectations, but it’s likely multiple factors. On the positive side, medical residents, like their fellow “Generation X” age peers in other fields, surveys show, appear more aware generally of the importance of avoiding job burnout and jeopardizing their feelings about their work. This particular generation, recruiters and residency directors report, places a commensurately higher value than their older counterparts on having a “quantifiable” work life and reserving defined time for non-work pursuits.
“The duty-hour restrictions [imposed in 2003] probably contributed to this shift,” said Gopal Yadavalli, MD, director of the internal medicine residency program at Boston University. “Before, there was this expectation that you ‘stay until the work is done,’ but people graduating over the last decade have been in a different environment with the 80-hour work weeks and 16-hour shifts. This mindset influences the trainees, and perhaps colors their expectations too.” Anecdotally, Dr. Yadavalli notes, he isn’t hearing reports from recent graduates about mismatched workload expectations once the physicians get into practice. Those he has heard from, most of whom are in academic positions, “seem quite happy with their schedules,” he said, even if some struggle to obtain protected time for non-clinical activities.
The case might be different for internal medicine graduates going into community practice settings, Dr. Yadavalli acknowledged, noting that graduates who choose hospitalist positions appear less satisfied with their schedules and associated demands than those in academic practice.
One upside of the new generation’s quest for balance in their work and personal lives — young physicians want to be more available to spouses and children than perhaps their own parents were, and keep a routine workout schedule — might contribute to untenable expectations, observed Craig Fowler, immediate past president of the National Association of Physician Recruiters. “To their credit, this group of young physicians want to be all things to all people. They want to be high-performing clinicians but also show up at their child’s soccer games, and be around most nights for dinner,” said Mr. Fowler, senior vice president for the recruiting firm Pinnacle Health Group in Atlanta. “That’s commendable, but it might not be ideal for the community or organization the physician wants to join.”
Several recruiters reported that residents in the specialties generally don’t request, or expect, as much in the way of work-life balance accommodations as those in primary care. This might be attributable to the culture in their residencies regarding work expectations, some recruiters ventured, or because they’ve had more exposure to practice-life realities because of the additional time they spend in training. And in specialties where supply does not outstrip demand, savvy residents might be less inclined to ask for concessions, some sources said.
“We see this more in primary care — physicians starting the conversation with questions about call and the work schedule, and the amount of compensation — than among specialists. The primary care physicians know that because of the market, they can be very choosy,” said Kathryn Zimmerman, MBA, director of physician network development with Adventist HealthCare in the Maryland region near Washington, DC. “At the same time, I see a lot of passion in these young PCPs and a commitment to good clinical care and outcomes. Still, it is a bit of a turnoff when people lead with special considerations.”
The picture appears to be somewhat different in certain small specialties, where clinical practice and setting specifics might take higher priority than life-style considerations for job-seeking physicians. In child psychiatry, for example, even though the shortage is perennial, physicians might hold out for a type of practice structure, observed Eugene Beresin, MD, a professor of psychiatry at Harvard Medical School and senior medical educator in child and adolescent psychiatry. “Our trainees are seeking positions that enable them to achieve what they went into this field for — to help children and families, and to be able to do some psychotherapy. They’re not wooed by positions that offer no call or high compensation,” Dr. Beresin said. “At the same time, they’re extremely aware of and concerned about the challenges they’ll face in balancing their professional and personal lives.”
What the ads don’t say
The shortages in primary care and some specialties, often underscored by the barrage of communication residents receive about practice opportunities and the tenor of associated advertisements, might be skewing physicians’ expectations about how flexible positions (and employers) might be. Several other sources mentioned the “sky’s-the-limit” advertisements that are becoming commonplace in primary care and the specialties.
“For locations that are challenging to recruit to, we see advertisements that offer not only large sign-on bonuses and inflated starting salaries but also numerous life-style perks,” said Katie Cole, head of Harlequin Recruiting in Denver, which specializes in the neurosciences. “Candidates coming out of training are bombarded by these offers and think that they’re able to hold out for every item on their wish list. But that’s not the case when the opportunities are in high-demand, desirable areas.”
How and when to ask
While most physicians are gracious in making their requests, even if their “wish list” is a tad extensive, some are too aggressive and demanding, some recruiters maintain. Recruiters, and likely employers too, take issue with candidates who lead with the money card — asking for compensation above the median — but don’t appear willing to perhaps work extra hours in exchange or let go of other work-life balance requests such as preferred work-week or call schedules.
A more appropriate approach to requesting work-life balance accommodations, Ms. Levison advises, is for candidates to first state what they bring to the table and in skills and qualifications, before divulging the wish list. Then, she added, physicians should be prepared to offer something to counter their request. “If a candidate doesn’t want to work five days because she wants the fifth day for family, but is willing to work three or four long days, that will get the attention of groups that want to staff longer on weeknights or flex their staffing,” she said.
What doesn’t work, all recruiters interviewed agreed, is when candidates propose a lopsided arrangement with no give and take, from the start. Even worse, perhaps, is a candidate who goes through several conversations and a site interview before dropping a laundry list of work-life balance requirements on the table when an offer is imminent. In any conversation with a recruiter or prospective employer, physicians should be gracious, first and foremost, and should err or the side of appearing flexible, not rigid. “It’s best to leave your demanding attitude at home,” Ms. Levison said. (See “Do’s and don’ts” at the end of the article.)
“When I recruit for internal medicine and family practice positions, many candidates today tell me exactly what they want in terms of work-life balance,” said Mr. Kashnig. “So sometimes I have to counter by letting them know what we can accommodate and what we can’t — and that we’ll adapt within reason.” For example, Dean Medical Group has structured its primary care practices to allow for part-time practice (a minimum of three-quarters time) and job sharing, where feasible. However, all physicians must work some evening or Saturday hours, and take very limited call.
What the medical group won’t accommodate, Mr. Kashnig points out, are patently unreasonable requests — such as four-day work weeks, with Friday off, and no evenings or call. “Most physicians are civil, but we do occasionally run into graduates who want more [compensation] than we can pay or aren’t willing to work with our schedules. And if their expectations are unreasonable, we tell them,” he said, adding that a demanding attitude in a new graduate is a definite “red flag.”
Work-life balance requests: Do’s and don’ts
Most medical practices and health care organizations will try to grant highly qualified physician candidates’ requests for part-time schedules or other accommodations, within reason and to the extent feasible, provided the physician is willing to give something in return and the request doesn’t conflict with established culture.
In these discussions, as in anything that involves potentially complex or sensitive negotiation, there’s an etiquette of sorts. Recruiters who shared their perspectives for this article offered additional guidance for candidates on how to navigate these discussions.
Share your strengths before asking for accommodations. “What recruiters want to hear, before making concessions, is that is that you’re highly qualified and committed to your specialty but also willing to put down roots, grow the practice, and cultivate patient loyalty,” said Ms. Zimmerman.
Articulate what’s important. Decide what’s most important — is it a three-day work week or very limited night call because of family considerations? — and lead with that, Mr. Guyant advises. “Many candidates, when I ask what’s most important or less important besides compensation, and why, can’t always tell me.”
Broach the big-picture or “must-have” needs early, before interviews start. Timing is important, Ms. Streicher reminds candidates, to avoid wasting anyone’s time. “It’s best to be open, early on, particularly if you want a part-time schedule, so that the recruiter can make a good match. And do ask questions about the job’s fixed requirements, before you talk to anyone in leadership,” she said.
Be prepared to pare your wish list — and keep it short. “You won’t get 100 percent of what you want in schedule or life-style accommodations, so don’t shoot for the moon. And do rate and rank your priorities, ideally before you start exploring opportunities,” Mr. Fowler advises.
*Dr, Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.