Residency Graduation Toolkit

Residency Graduation Toolkit



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The transition from training into independent practice is fraught with challenges and is often quite stressful. The intent of this information is to provide a guide to help ensure that critical issues are being addressed in an effective and timely manner. The aim is to help the reader secure and thrive in a job that will keep him/her happy and fulfilled during the first 3 years after training.

Beginning the Job Search
Many graduates begin their search based upon location or a specific position (i.e. academic, private practice, hybrid etc.). If location is the primary determinant, then looking for a job may extend beyond looking at the classifieds. Search for clinics in that locale, call the office, ask to speak to the office manager, and inquire about any current or expected future openings. It may help to fax or email your cover letter and CV first so you can then mention that you sent them to the office manager. Often "cold-calling" or e-mailing practices in this manner can get an applicant in the door. And if a group is not currently hiring, they may place your application higher on the pile for the future, when a position does become available. Many people also choose to work with a recruiter for their job search. Whatever you choose, remember to use all the connections at your disposal.

Elements to Consider In Your Desired Practice

There are myriad elements to consider when evaluating a practice. Below is a list of some of the important aspects to think about.

The Facility

  • Location(s)
  • Hours of operation
  • Size: How many pediatricians? NPs/PAs? Lactation specialist? Social worker/care coordinator?
  • Patient demographics: languages, insurance, socio-demographics, etc.
    • Second language nice vs. necessary? Does group have an interpreter service?
  • Personal office, nook/area, or desk that you can use to store your resources?
  • What measures are in place to promote continuity between patients and doctors?
  • Record keeping system: electronic vs paper vs hybrid. How long have they had this system? Do the providers like it? What are its pros and cons? Are they currently transitioning systems or considering that in the near future?
  • How long have the nurses and office staff been there? (i.e. turnover rate for staff)
  • How do they attract new patients? What, if any, advertising do they do?
  • Local competitors?
  • Inpatient
    • Available lab and radiology services?
    • Level of care and services provided? Are patients referred externally for certain sub-specialties? If so, what is the process?
    • Number of hospital beds?
  • Outpatient
    • Rooms per provider: 3 considered an acceptable industry standard
    • Vaccine policy? Are vaccines for privately paying patients consistently stocked?
    • How is the scheduling template broken down? Below are some typical ranges:
      • 10-15min for sick visits
      • 20-60min for newborn
      • 15-20min for regular checkups
      • 20-40min for adolescent checkups, new ADHD evaluation, and other complex issues
    • No-show rate? Does the practice overbook to ensure full schedules?
    • Who handles referrals? Process?
    • Which labs do they do in-house? Where are send-out labs drawn? Turn-around time?
    • Where are radiologic studies—e.g. basic X-rays—performed and what is the turn-around time for results? Are you able to see the images yourself?

Your Duties

  • Full time vs. part time and how many days (full time is usually 4 - 4.5 days, part time is usually 2 - 3.5 days)
  • How is call handled? Weekends? Holidays?
  • Inpatient
    • Average patient census?
    • Call responsibilities: How structured (e.g. number of weeks, split days/nights, etc.)? Are trainees/mid-level providers available? Estimated frequency you to go in afterhours?
  • Outpatient
    • Which clinic location(s) (if more than one exists)
    • How many patient encounters per day?
    • Any nursery or hospital duties? What does this entail?
    • Call responsibilities: Average calls per night? Would you ever have to go in to the office/hospital/nursery outside of clinic hours in response to a call?
  • Do you need to supply your own otoscope and/or ophthalmoscope?

Social

The Interview
After finding an interested practice, hospital, or academic center, your next step is to prepare for the interview. Learning everything you can about the group and position will determine if it's the right fit for you and help you to sell yourself to your future employer. Listen to former pediatricians who have worked at that facility. Take heed if they share concerns with you (e.g. administrative issues). This is not uncommon, especially if the administrative leadership expects you to function as an experienced physician. Resources are listed below to help prepare for questions you'll be asked as well as what you should/should not ask. Again make sure you take the mindset that you are interviewing them as much as they are interviewing you.

  • Interview Tips
  • Practices/companies/hospitals pay for your interview expenses. What might cost you money is buying the perfect suit for your interview day (one that fits after three years of residency).
  • Other questions
    • Why are they hiring? If a previously existing job, why is it now vacant?
    • What has been the turnover rate in that position over the past several years?
    • What is their decision timetable and when will they notify you of their decision?
    • Opportunities for advancement and/or partnership?

The Contract

  • Note: many practices prefer to discuss these after an offer is made.
  • Everything is negotiable.
  • Paying a lawyer with experience in medical contracts to evaluate your contract can be an excellent and worthwhile investment.
  • Salary is one part of the overall compensation package. The Bureau of Labor Statistics has info about general pediatric salaries across the country. PedJobs also has links to various websites that can provide information (some for a fee).
    • Is the salary fixed?
    • Incentive payments?
    • Production/performance bonuses?
    • Standard raises each year (percentage vs set amount)?
    • Keep in mind that bonuses are one-time events whereas raises carry over into subsequent years.
  • Benefits (medical, dental, life insurance, 401k, etc) and details of each if offered. How long must you be employed before each benefit will start or be available?
  • Loan repayment? Many practices are now offering loan repayment programs.
  • Malpractice insurance (usually the practice covers this).
  • Non-compete clause: delineates where you are excluded from practicing (usually expressed by city, county, or mileage) and is limited to a specified time frame after you leave the practice.
  • Vacation/Paid Time Off (PTO). A vacation "week" is usually similar to how many days you work per week (ex: if you work 4 days a week, then 3 weeks of PTO is 12 days). What other holidays are observed (i.e. clinics are closed)? Do clinic closings for inclement weather count toward your PTO?
  • Maternity/Paternity leave details.
  • Professional stipend for CME, AAP membership dues (National/State), etc. ($500-$1500). Some practices automatically pay for some of the above and have a separate stipend.
  • Duration: One year is typical. Some contracts must be renewed yearly for a time while others automatically renew.
  • Is there an employee manual to which you are also expected to abide that is not detailed in the contract?
  • Tail insurance: a lump sum due to the malpractice insurance company when you leave a clinic to "cover your tail", which will take care of any future claims made about your care provided while at that clinic. How long must you work there before the practice would cover your tail insurance?
  • Any negotiation you want to ensure will be honored should be written in your contract.
  • Unless your contract says otherwise, you can break it at any time as long as you give notice the required number of days before you leave (typically 60-90 days).

Loan Repayment
The NIH has an "NIH loan forgiveness" program (Public Service Loan Forgiveness Form). The program is for individuals working for a non-profit. If you qualify, the Public Service Loan Forgiveness (PSLF) Program forgives the remaining balance on your Direct Loans after you have made 120 qualifying monthly payments under a qualifying repayment plan while working full-time for a qualifying employer.

If you are embarking on a research-focused career, consider the following: https://www.lrp.nih.gov/index.aspx

Moving
Ask for a moving allowance. Employers usually start at $3,000 US and you can negotiate for the cost of relocation of all your possessions from your current location to your new home by a professional moving company.

Buying a Home
This depends on your situation! Do not buy until you are prepared to take care of a home and confident you will be settling in the area for at least a few years. There are multiple companies that provide "Physician Mortgages" for little to no money down. They also allow you to close earlier than 30 days from the start of your job to give you time to move and settle in before starting. As above, you may want to give your first job a year before you decide to buy in case you hate the job or the area. Also, not buying a house up front gives you more negotiation power in your contract. They have to try to entice you to come/stay rather than already knowing you are committed to a house. And if for some reason the job is a poor fit, it is much easier to leave if you don't have to worry about selling a house.

If you do decide to take the plunge however, Citywide Home Loans and Suntrust are a couple examples that offer Physician Mortgages. Others likely exist as well, just check around in your area. It doesn't matter what mortgage company you work with but ensure that you trust them. Get suggestions from your institution, a co-worker, or friend in the area. 

Licensure and Credentialing
The list of licenses and credentials needed to practice is extensive: State medical license, DEA license, state pharmaceutical license, NPI number, malpractice insurance, and hospital credentialing, etc.

Medical License
Requirements for licensure vary by state, but all work in conjunction with the Federation of State Medical Boards. Most states will require extensive amounts of paperwork as well as verification by the Federation Credentials Verification Service (FCVS) which can serve as a convenient storehouse for important documents: Education history (pre-med, medical school, residency, fellowship), licensure examinations, GME, etc. FCVS is a separate service that verifies all of your education, so you don't have to continually send transcripts and other official documents to each board you apply to. Consider visiting the FCVS as your first step in the application process because FSMB and many state specific license applications will often require an FCVS profile to auto-populate portions of their application. 

It would be prudent to start the process of applying for state medical licensure as soon as you get a job/know what state in which you will practice. It is often possible to apply for an unrestricted state license after completion of your intern year. Ideally, this process would start in January of the year you graduate. Each step involved takes weeks-to-months to process, so starting early will ensure you get your license in time to start a job in July. Below are links to FCVS and FSMB.

The FCVS base fee is $375 but will ultimately cost about $575 to create a complete application. Each subsequent profile report is $95; this is if you decide to change states and have a new application later in life.

FSMB provides an electronic Universal Application (UA) that most states accept as the beginning of your state licensure application, this costs $50 and you only have to pay once even if you send it to multiple states. Each state will likely have its own supplemental requirements in the form of background checks, further paperwork, etc. Those packets can be printed from the UA website when you designate which state you are applying to.

Contact individual states for their specific requirements. Each state also has its own separate licensing fee in addition to the FCVS/FSMB fees. These fees are in the $250-$1000 range, depending on the state.

Note: Many of the documents above will require notarization. 

DEA
A DEA license is required to prescribe medications. Make sure to renew or apply before your training DEA license expires, or else you may suffer additional fees and/or paperwork. You must have an active state license to apply. Some states require a separate state-controlled substance license as well. The cost of a DEA license in 2018 was $731; the license is valid for three years. There are many caveats regarding the DEA license, so please review these sites for complete details: http://www.deadiversion.usdoj.gov/http://www.deadiversion.usdoj.gov/drugreg/faq.htm

Hospital and Insurance Credentialing
Hospital credentialing is typically started 3-4 months in advance of start date. The office manager or program coordinator if you are going into fellowship should be able to provide you with these packets. You will find that all the paperwork is very repetitive from what you just completed to get a state license. This will often come with its own fees as well.

Insurance
Insurance coverage is a very personal topic and so we are not making specific recommendations. Below are some aspects to think about when making decisions.

Disability
If you are interested, obtain disability insurance while you are young and healthy as this will have the strongest impact on your premium and other fees. Remember to read the fine print and be clear on how "practice" is defined. For instance, an interventional cardiologist can hurt his/her hands, but still practice general cardiology. Make sure you understand exactly when your policy will become active.

If offered by your employer, there may be two sign-up periods: upon starting and upon partnership. Consider obtaining your own policy if your employer only offers it to partners. If you have a policy, definitely compare the two to ensure you have the best deal.

Life
As a resident member, you were provided complimentary $100,000 Group Term Life and $1,000 per month Long Term Disability insurance, provided by the AAP Group Insurance Trust. This valuable coverage is under the oversight of AAP staff and members and offers group rates that are available only to AAP members. The Plan is administered and managed by USI Affinity—our endorsed insurance partner—and underwritten by New York Life Insurance Company—one of the largest and most respected insurance companies in the nation. If you did not convert your complimentary coverage by October 31, 2017, you can still apply for up to $2,000,000 in benefits as an AAP member. This is a great way to protect your family.

Here are a few highlights of this affordable coverage:

* Rates are for AAP members only and not available to the general public

* No medical exam or health questions required to continue your coverage               

* Benefits are paid directly to you or your beneficiary(ies)

* Coverage is portable—you can take it with you if you change jobs—as long as you remain an AAP member

Malpractice Insurance
Malpractice insurance is a separate product that covers a provider's liability. These plans often entail significant paperwork. Applicants need proof and details of the malpractice insurance policy from his/her training programs—applications often ask for the last 10 years of malpractice policy information. If your program uses trainee tracking software—such as New Innovations®--this information may be uploaded to the trainee's profile page along with many of the other documents listed below.

Documentation to Keep Readily Available

  • Below is a list of potential documents applicants are likely to need on hand for the various licenses and credentials. ($) indicates a separate, additional fee:
  • Diplomas
  • Medical school documents
  • Fingerprinting (both local and FBI) ($)
  • Immunization history
  • Passport photo ($)
  • Social security card
  • Curriculum Vitae
  • Moral character references
  • Letter of Good Standing from all states where the applicant holds a license
  • National Practitioner Data Bank Report ($)
  • Postgraduate training completion certificates (optional)
  • PALS/NRP/ACLS certification
  • Copy of prior malpractice insurance policies
  • Copy of current state medical license
  • Copy of current DEA number (both state and federal)
  • Copy of NPI letter
  • AMA physician profile ($)
  • Child abuse clearance
  • Marriage certificate (if applicable)
  • Divorce decree (if applicable)
  • Name change document - Court Issued (if applicable)
  • Naturalization certificate (if applicable)
  • Baptismal certificate (if applicable)
  • Birth certificate
  • Refugee travel document
  • Fifth pathway certificate (if applicable)
  • ECFMG certificate (if applicable)

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