Education Lessons Medicine

Negotiating a Job Offer (IV).

Negotiating a job offer can make us all feel uncomfortable because the noise in our head stops us from asking for what we want (and often deserve). Ladies, this post is for you because, even as physicians, we still earn less money than our male colleagues[1. From the White House: In 2014, Women Continue to Earn Less Than Men. From Forbes: Even Women Doctors Can’t Escape The Pay Gap.] and we often do not assert ourselves as much as we could during negotiations. That doesn’t help us as individuals or as a population.

One of the most important things to keep in mind during negotiations is that you’re not asking for “too much”. You are going to work hard for your employer. You want to arrange the details of your job so that you can create your best work with as few obstacles as possible.

As a resident, we had to pay for parking on nights when we were on call. We all hated that. Why do we have to pay for parking when we’re in the hospital working all day, then all night, and then for most of the next day? If we could have negotiated our jobs so that parking was covered when we were on call, then we would have felt less resentment about our roles. This is an example of a psychological obstacle that could get in the way of doing your best work.

First, consider that it is your employer’s job to say “no” to any negotiation request you make. That doesn’t mean that s/he will say no. If you assume that it is your employer’s job to say “no”, though, it’ll make negotiations feel less personal. (This is an example of a mental shift that is meant to help you, even if it is inaccurate. Sometimes cognitive distortions are helpful.) This mindset will also help you assess your priorities during the negotiations: What matters most to you, where you won’t take “no” for an answer? What is less important, but would be nice to have?

Second, consider it your job to ask for everything you want. By asking for everything you want, you demonstrate multiple things to the organization:

  1. You have the confidence to ask what you want.
  2. You show your strong communication skills in asking for what you want.
  3. You have the skills to advocate for yourself.
  4. You can use those same skills to advocate for your patients, your colleagues, the organization, and other parties.

On a practical level, naming everything you want also provides room for compromise. Your inner critic may balk at the idea of asking for everything you want (“I’m asking for too much!”). Organizations use your inner critic to their advantage because they know it is difficult for potential employees to ask for what they want. However, organizations need employees and, if they’ve already offered you a job, it shows that they specifically want you.

Know your style when it comes to negotiations. Some people aren’t “phone people”. Some people prefer conducting negotiations over e-mail, where one can take time to mull over options before responding. Some people prefer having conversations in person. This last preference has an advantage over the other two: It is hard to say “no” to someone’s face. Negotiating in person also sends a meta-message that you can manage potentially uncomfortable conversations with skill.

Lastly, remember that potential employers should be on their best behavior during interviews and negotiations. If they aren’t treating you with respect when they ought to be courting you, how will they treat you once you are formally working for them? All of these interactions provide information: Do you want to work for someone who isn’t putting forth a best effort to impress you? You’re likely working hard to make a good impression on them, right?

I hope the posts in this series will help you have more confidence and skills as you seek work. People often talk about “self care”, a concept that can sound hollow and corny. May these concrete suggestions help you in the realm of self care, as crafting a job that brings you satisfaction will help you take better care of your patients. Good luck.

Education Lessons Medicine

Negotiating a Job Offer (III).

We’ve discussed the value of a job description and a table of organization when negotiating a job offer. You can negotiate specific items on either one of the documents, now that you know how your employer has structured them.

Common and obvious things you can negotiate include salary (usually on the job description) and title (usually on the table of organization). The reason why these are common negotiating items is that, in some ways, they are the most flexible. The job might be in a clinic and everyone is expected to see patients between 8am and 5pm; that is not negotiable. How much you are paid, though, could vary. Title may not be as flexible, but, depending on your interests, there could be room to craft your specific title if it will accurately reflect what you do.[1. To be clear, titles, at the end of the day, are just words. Some people believe that achieving an important title grants you leadership, influence, and power. I believe that who you are matters more than what your title is. We’ve all known people with fancy titles who do not appear to have the substance to support the description of their position. We also have met people who do not have fancy titles, but have integrity and wisdom and, as a consequence, influence and lead others. Yes, titles can give you access to information and people that you might not otherwise have. When you go home, though, you bring along whoever you are, not your title.]

For example, if you’re interested in education and would like to run a regular journal club and case consultation series, you could negotiate a title of “assistant medical director of education”. I’ve recently heard about some physicians who applied for “medical director” posts, but all the other leadership staff were “chief [blah blah] officers”, so they negotiated for a “chief medical officer” title. Again, from my perspective, the substance of what you do is more important than what words people call you.

Here’s a list—in no particular order—of stuff you can negotiate:

Bonuses. These seem rare in medicine, though some people are offered “signing bonuses”, particularly when they join hospital systems. You could negotiate the value of the bonus… or you can fold this into your salary so that your regular salary is higher.

Time off. If your employer can’t increase your salary, could they give you more vacation days?

Part-time, full-time, flex-time. Perhaps the job is posted as a part-time job, but you would like to work full-time. Or maybe vice-versa. If the fit is good between the employer and you, they might accommodate your preference.

Scheduling. Instead of working five 8-hour days, maybe you could work four 10-hour days or three 12-hour days. This depends on the setting, of course: Some clinics will much prefer that you are present five days a week for urgent appointments and coverage. They also may not have clerical and other staff available to work outside of the standard 8-hour day.

CME. Look at the job description: Does it mention CME? If not, ask for both time and money. Under the best of circumstances, you would get paid your regular salary while you are away and the employer would cover the cost—registration fees, hotel, travel—of attending any educational events.

Licensure. If the job requires that you maintain an active state license—which it should!—then you can ask if the employer will cover the cost of your license. You could also ask them to pay for your DEA license.

Transportation costs. If travel is part of your job—maybe you work in different clinics throughout the week—you can ask the employer to pay for your bus pass or reimburse you for gasoline or miles driven. Is there a company car you could drive?

Administrative support. Can you have a dedicated staff person to fax prescriptions for you? Format letters you write? Help with scheduling meetings or appointments? The employer is paying you to see patients; they don’t want to pay you to fax prescriptions.

Non-clinical time. If the job description includes administrative, teaching, or research duties, you can negotiate for more time or resources to do those things.

Office space. Maybe you can negotiate for a bigger room. Or the corner office. Or a room with a window. Or a quiet space.

Malpractice insurance. Many large physician employers already pay for this, but if your employer doesn’t, ask them if they will.

Call. If taking call is part of the job description, you likely can’t negotiate the amount of call you take because people probably aren’t paid extra money to take call. You could negotiate a decrease in salary amount if you don’t want to take call. Or you could negotiate when you take call—for example, you’d prefer to take call in week-long chunks instead of every fifth night.

No compete clauses. This is that thing in a contract that states that, if you leave the organization, you can’t practice within fifty miles of the clinic for five years and you can’t take any of your patients with you. If you plan to stay in the area, keep an eye out for this and know that fifty miles is a lot.

This is just a short list: Depending on the context in which you work, there may be other (obvious) things that you can negotiate.

It may seem daunting to ask for any of the items in the above list… but it doesn’t hurt to ask. I’ll talk more about that in the last and final post in this series.

Education Medicine Systems

Negotiating a Job Offer (II).

The second thing to ask for when negotiating a job offer is a table of organization. Like the job description, if you are able to review this during your interview, do so. That will give you the opportunity to ask clarifying (not negotiating) questions during the interview.

A table of organization is a sheet of paper with boxes and lines on it that tells you who reports to who. It shows the official hierarchy of the organization. Your position should be on the table; there should also be a line from your position that leads up to your direct supervisor. It should also indicate who reports to you. Many organizations will not share this information with you before you are hired unless you ask for it. Some organizations don’t share this information with you even after you are hired.

If you have Machiavellian ambition, the table of organization also provides a roadmap as to how you can get to the top.

But even if you are not a fan of Machiavelli, the table of organization gives you useful information. Say you want clinical consultation related to the practice of medicine. Your supervisor, however, has the letters “MBA”, “LICSW”, or “JD” after their names. You thus can expect limited assistance from them. Maybe your supervisor is a physician, but is in a different specialty. Clinical consultation may not be useful there, either. Find out before you start a job who will provide clinical supervision for you.[1. If you don’t have an official clinical supervisor, make a point of finding out where you can get help for clinical matters because we all need it sometimes.]

If you have questions or concerns about issues related to the system of care, it’s useful to know if your supervisor can help. It’s also useful to find out who your supervisor reports to (and so on up the chain) because that will affect what information you have access to, how you are treated, etc. For example, as a staff physician, the table of organization might show that you eventually report to the Chief Medical Officer, who might then report to the Chief Executive Officer. However, it is also not unheard of for staff physicians to report to a medical director, who then reports to a director of clinical services (who may not be a physician), who then reports to a deputy director, and then an executive director. If the director of clinical services doesn’t like doctors, or the medical director doesn’t advocate for the medical staff, then your requests might not get the attention they deserve.

You might also find yourself reporting to more than one person. Depending on who they are, that could be fine… or you might feel like a kid with bickering parents.

The table of organization will also tell you who you supervise (if anyone at all). Maybe you don’t want the responsibility of having subordinates. Maybe you do. Maybe you want that possibility in the future, but not now. And maybe the table shows people reporting to you that you are not qualified to supervise. For example, you might have a cadre of nurses reporting to you. There is overlap in the knowledge that physicians and nurses use in their work, but most physicians do not have the skills or expertise to provide satisfactory clinical supervision to nurses.[2. Just because you have the letters “MD” after your name does not mean that you are qualified to supervise everyone, just as someone with the letters “MHA” after their name doesn’t mean that they are qualified to supervise you.]

Do also note that the table of organization you receive from your employer is the “formal” table of organization. There exists in every organization an “informal” table of organization. You usually learn about the “informal” table through word of mouth. Maybe people are supposed to report to a specific individual, but they actually talk to someone else on the other side of the table for help and information. That’s not information you might get during the interview process, but if you have inside connections or opportunities to talk with current employees, you can ask.

For example, maybe the official supervisor doesn’t actually provide useful supervision and you’re better off talking to another staff physician. Or maybe the medical director isn’t assertive, so if people want the Vice President of Clinical Affairs to know something, they cultivate some sort of relationship with that VP or someone along that chain.

This sounds like “politics”. Where there are people, there are often politics. You, however, want to be prepared: When problems come up—and they will—you want to know who you can and should talk to.

Next post: Stuff you can negotiate for.

Blogosphere Education Medicine

Wanna Help Me with My Talk?

I’ve been invited to give a talk to psychiatry residents about “psychiatrists and social media” and my own experiences as an online physician.

Could you, fine reader, help me by telling me why you read the writings of physicians online?

This can include blogs, the 140-character musings on Twitter, blurbs on Facebook, or the myriad options now available.[1. I started writing online when “social media” wasn’t in the vernacular, there were only “weblogs”, and a 56 kbit/s dial-up modem was considered speedy. Now get off my lawn.]

For visual interest, post your response on Twitter, Facebook, or Ello so I may snag a screenshot for my talk. You can also send me an e-mail; just make it clear that I can share the content of your note.

Thank you for indulging me.

Education Lessons Medicine Systems

Negotiating a Job Offer (I).

The first thing you should ask for—if you haven’t already received it—when negotiating a job offer is a job description. This is a document that often has bullet points that describes the title and duties of the job, required and preferred qualifications of the applicant, and basic (and sometimes vague) information about salary and benefits.

Sometimes employers post the entire job description as a classified ad. Sometimes they post an ad that is a three-sentence summary of the job description. Sometimes they send out an e-mail that announces a job opening. Sometimes you hear about a job from a friend and you’re invited to sit for an interview when you call the employer to express interest.

The point is that you could end up sitting for a job interview without ever seeing a formal job description. If you can get a job description before or during the interview, get it: You can ask clarifying (not negotiating) questions during the interview.

It sounds obvious, but the value of the job description is that it tells you what your employer wants you to do. You learn what is expected of you and what you can expect in return.

Maybe you prefer hospital work to clinic work. The job description should tell you if you have to do any clinic duties, such as providing coverage when people are on vacation. If you will be conducting research, teaching, or doing administrative stuff, the job description should tell you how much time and other resources you will have to do that work.

Without a written job description your employer could shift or change your job duties in what seems like a unilateral fashion:

“But when I interviewed, you told me that I would never have to cover the inpatient consult service.”

“Well, that’s where we need coverage right now. Starting next month, we’d like you to do that two days a week.”

Thus, the job description also provides the basis for job negotiations. Review the job description to see if anything is missing (like specific job duties, particularly things you like to do) or if there are details that you want changed (perhaps you want more leadership responsibilities that merit a higher salary).

The job description can provide the foundation for a job contract (or a “hire letter”, as some agencies don’t use contracts). Not every detail about your job has to be in writing. For those details you care about, though, written descriptions of your role and responsibilities make expectations clear to both you and your employer.

Sometimes employers—such as small agencies or new, innovative programs—don’t have job descriptions. Maybe the job description is vague (“will provide clinical services”). What should you do then?

You’ll have to look for other cues during the interview and recruitment process to discern how much to push for a job description. In some cases it is clear that a job description won’t be useful. Consider a start-up project, where no one can anticipate what the program will eventually look like or how your role will evolve over time. Maybe the organization only has ten people and things are routinely discussed and resolved informally. To be clear: If the employer doesn’t give you a job description, that doesn’t automatically mean that the employer is going to screw you over. It just means that they don’t have a job description to give you. It also suggests that you have the opportunity and flexibility to tailor the job to your specific interests and strengths.

Given the often rigid structure of medicine and that physicians are trained to do specific things, we may not think that a job description can help us (“I’m going to work as a doctor”). Asking for a job description, though, can help you shape your job so that your work life is as fulfilling as possible.

Next post: The second thing you should ask for.