There are three vital issues for sub-specialist physicians that must be addressed in any physician employment agreement: compensation, marketing, and maintaining proficiency in your specific sub-specialty.
Compensation Issues for Sub-Specialist Physicians
One of the common issues for sub-specialist physicians I have seen repeatedly when performing a physician contract review is being offered what “everybody else” in the department or practice makes. The obvious problem with an offer like that is that “everybody else” didn’t complete the extra year or so of training (and forgo a year or so of attending physician income) to become a sub-specialist that you did.
Although you might understand some resentment for the “new physician” who is making more than established physicians in the department or practice, the offer you receive should comport with benchmarks for your sub-specialty. Too often, the sub-specialist is presented with the line that this is “our standard physician employment contract.”
There is a reason that Medical Group Management Association and other consultants publish separate benchmarks for sub-specialists. Sub-specialists almost always make more than “mere” specialists. Any offer should comport with MGMA benchmarks that are relevant to you.
Marketing Issues for Sub-Specialist Physicians
Another issue for sub-specialist physicians I frequently see is that the practice or department “intends” to grow the sub-specialist’s practice. They are generally not being disingenuous – they really are hoping that, somehow, your practice will grow. They may not have thought through what that means in practice, however. “Build it and they will come” may work for baseball fields, but it rarely is a formula for success in building a physician’s practice.
The employer should be willing to set aside a specified amount for marketing, and share with you at least a rough sketch of how the money will be used to specifically build a practice in your sub-specialty. Another marketing expense that tends to be overlooked, or not addressed in detail, is how your time will be spent. You are drawing a salary, so your time is a valuable commodity. The employer should be willing to agree that you will be given the time to grow your practice. This can sometimes be addressed by reasonable patient contact hour requirements – related at least mostly to patients who need your sub-specialty.
I often see lip-service about how the employer will support the growth of the practice. However, in a busy practice or department, day to day demands on the other physicians make it extremely tempting to fill your schedule with patients who don’t need your sub-specialization. After all, you are board certified in that specialty, so why should you have a reduced patient contact hour schedule when there are patients waiting to be seen that you are perfectly well qualified to treat?
This issue is intrinsically woven into the final issue for sub-specialist physicians – maintaining proficiency in your sub-specialty.
Maintaining Proficiency in Your Sub-Specialty
This last of the issues for sub-specialist physicians may not seem like one you should worry about as a sub-specialist, but it can become a problem if you join a busy practice or department. Although the employer may in good faith want to grow your sub-specialty, often the other physicians without the sub-specialization are swamped. The neurology practice may be overwhelmed with patients needing to see a neurologist, so scheduling these patients with a headache specialist seems like a no-brainer. Similarly, there may be a genuine shortage of anesthesiologists in the hospital, so why not use a cardiac sub-specialist to treat them? You are qualified to treat these patients, so why shouldn’t you?
The answer, of course, is two-fold. First, you can’t concentrate on letting the community know about your expertise and availability if you are spending all of your time treating patients outside your sub-specialty. Secondly, it is obviously difficult to maintain your proficiency in your sub-specialization if you are not spending a material portion of your time practicing in the sub-specialty.
It’s a difficult situation for both the employer and the physician. Both parties want to grow the sub-specialty, but both parties also want to do the very best they can for existing patients. The employer may be paying you more than the other physicians in the group, so there is even more pressure for you to “produce.” The issue of patient contact hours is, therefore, even more critical for sub-specialist physicians than for other physicians. Not only the number of patient contact hours, but also the patient mix (i.e., those needing your sub-specialization versus those who do not) should be addressed in as much detail as possible.
The issue of patient mix is easier to address if you are not the first sub-specialist in your field working for the employer. If the hospital has a growing cardiac program, with a few cardiac anesthesiologists already on staff, it will be more comfortable specifying your patient mix than a hospital that hopes to grow its cardiac program.
Although it wouldn’t be an issue in an ideal world, it’s also important to get a feel for your colleagues before accepting the position. If a busy neurology practice compensates its physicians on productivity compensation, those physicians may be less likely to refer a headache patient to a sub-specialist than they would be if they were paid on a straight salary. You will probably have to follow your gut in making this decision, but a site like Rate Your Healthcare Employer might be useful in this regard.
You stuck it out even longer than the incredible commitment that your colleagues endured to become an attending sub-specialist. You deserve a fair employment agreement.