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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.

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Education Informal-curriculum Lessons Medicine Systems

Negotiating a Job Offer (introduction).

I recently gave a talk to psychiatry residents about how to negotiate a job offer.[1. The focus on the talk was on negotiating a job within an organization that is already established—a “typical” job for a physician. There is more flexibility—and uncertainty—for start-ups and other innovative programs that deviate from standard models of medical practice. For those of you who are trying/creating something new and different, good for you: We need you.] Our resident cohort did not receive any formal instruction about this[2. When I was a resident a few attendings in private practice did talk with us about how to hang up our own shingles. Most of the people in my cohort did not go into private practice.] and I don’t know if this is a topic that is common in resident education. It seems that physicians, as a population, aren’t skilled in negotiating job offers.[3. I wonder if physicians don’t think or learn about job negotiation because of our training experiences: To get into medical school we learn to jump through various hoops that others set aflame; we learn how to sit through interviews, though we’re rarely in a position to ask for what we want; we cannot negotiate where we go for residency; we are usually unable to negotiate the finer points of our clinical rotations; and, by the time we complete our residency training, we’re relieved to have more freedom and salary than we did as trainees, so we don’t ask for anything more.]

My suggestions for negotiating a job offer may not be comprehensive, though I hope that they will help new graduates and “early career” physicians have more confidence and skills when talking with potential employers.

I’ll write about two items of information candidates should always ask employers for. Most candidates don’t ask for these two items, though they can clarify the job, set expectations for both employer and employee in the future, and provide ideas for negotiations.

I’ll also share a list of negotiating items that are particularly relevant for physicians. Given that each specialty in medicine has its own practices and culture, consider the list a starting point.

Lastly, I’ll suggest general attitudes and perspectives that candidates (particularly women) can hold during the negotiation process to make it less daunting. Expect some cheerleading.

A caveat to begin: Do not start negotiating until a job has been offered to you. Even though you might burst with excitement about the job and believe that you are well suited for the work, the employer may not share your sentiments. Negotiating details of a job before it is yours is foolish. Imagine if the tables were turned: You’re sitting in an interview and you don’t want the job. Meanwhile, the employer is saying things like, “So… could you work every Thanksgiving, Christmas, and New Year’s?”

The interview process is your opportunity to ask questions, watch how the employer is behaving (because the people talking with you should be on their best behavior), and learn if you, the work, and the employer are a good enough fit. Though the employer initially has more power (as they are offering you a job, not vice versa), that doesn’t mean you are powerless: All the things you learn during the interview will help you decide whether you will accept their offer. And maybe there are some things you’d like to be a little bit different before you agree to work with them. That’s what negotiating is about.

Next post: The first of two things you should ask for during the interview.

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Education Funding Homelessness Medicine Nonfiction Policy Reading Reflection Systems

My Thoughts about Torrey’s “American Psychosis”.

This weekend I began and finished E. Fuller Torrey’s American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. (That’s not an inflammatory title. At all.) Though I have read a few of his articles, I have avoided reading his books. Part of this was due to all the other books I have wanted to read; most of this was due to my discomfort with how he frequently presents people with severe mental illnesses as dangerous and violent. Torrey is probably best known for his arguments to change the law so that it is easier to hospitalize people against their wills.

You can see how that is controversial. What his Treatment Advocacy Center says is advocacy, others say is coercion and social control.

In this book Torrey presents a history of the Community Mental Health Act of 1963 and presents compelling arguments that it was flawed since its inception. He also argues that patients with severe psychiatric conditions now continue to suffer consequences from the Act.

Although I do not agree with all of Torrey’s opinions, I do agree that the current “mental illness treatment system” doesn’t work. People—social workers, patients, nurses, therapists, case managers, psychiatrists—are all doing the best that they can, but the system could improve. A lot.

Fuller offers ten solutions to make the “mental illness treatment system” better:

Public psychiatric hospitals cannot be completely abolished. A minimum number of beds, perhaps 40 to 60 per 100,000 population, will be needed. This is approximately four times more beds than we have available today.

Torrey argues that a small percentage of people, due to their chronic and severe psychiatric symptoms, will need to stay in hospitals for a long period of time.

I am torn about that: On the one hand, I have my own anecdotal experiences working with patients who, with the “right”[1. “Right” is a relative term and depends on the individual. I also recognize that my anecdotal experiences are just that: anecdotal.] support, were able to stay out of hospitals despite their significant symptoms. The lack of public hospital beds forced all of us—the patients and the supporting team—to figure out creative ways to keep patients out of the hospital.

On the other hand, people get caught up in where patients with severe psychiatric symptoms are. There is an underlying assumption that being in a [state] hospital is bad, an evil to be avoided at all costs. Yes, there were and are hospitals that do not provide good care. That does not mean all psychiatric hospitals are terrible. Some people who are in jails, on the streets, or sitting in emergency rooms night after night are those who could benefit from treatment in public psychiatric hospitals.

As someone who has worked in all three systems—jails, homeless services, and emergency/crisis centers—I must say that the stability and structure of a [state] hospital is much more therapeutic and safe than the chaos often inherent in the other sites.

Lack of awareness of illness (anosognosia) must be considered when planning any mental illness treatment system and provision made for the implementation of some form of involuntary treatment, such as assisted outpatient treatment (AOT) or conditional release for approximately 1% of all individuals with severe mental illnesses who are living in our communities.

Prior to reading this book I had never considered the comparison of anosognosia in people with dementia with the anosognosia of people with psychiatric conditions. People readily commit people with dementia (who can be as violent, though perhaps without the same sense of purpose, as people with psychosis) into homes and institutions without discussions about their civil liberties. Why don’t we do the same with people who are psychotic?

The conditions are different, of course.[2. We will put aside commentary about Kraeplin’s dementia praecox for now.] Dementia is a global phenomenon; it affects nearly all spheres of a person’s existence. Psychosis is often sphere specific. There are people with psychotic conditions who pay their rent, buy food, take showers, and spend time with friends and family… and earnestly argue that cameras are monitoring them, that chips were implanted into their bodies in the past, and the FBI is trying to kill them.

The system often tries to avoid admitting people with dementia into hospitals for psychiatric reasons. Why? Because, at this time, we have no interventions or expectations that people with dementia will get better.

We admit people with psychiatric conditions into hospitals because we expect people will recover.

Community treatment of mentally ill individuals will only be successful if carried out by community mental illness centers, not in community mental health centers. The change of one word is crucial to the success of any such program. Mental illness centers may be freestanding or integrated as part of medical centers.

The italics are Torrey’s, not mine. You now see why Torrey calls it the “mental illness treatment system”.

While I agree that words matter, I don’t think using the word “illness” will endear the system to either patients or those who work in them. There is already stigma attached to psychiatric conditions. Who wants to walk into a “mental illness treatment facility”? Furthermore, when we do understand etiologies of psychiatric conditions, why not invest energy in prevention?

There are dialysis centers, children’s hospitals, and heart and vascular institutes. If a name change is indicated, why not “mental treatment system” or “mental institute”? Some people will maintain their mental health; others will receive active treatment for mental illness.

Continuity of care, especially continuity of caregivers, is essential for good psychiatric care of individuals with serious mental illnesses.

This is true for anyone for any condition (cardiologists and people who have had heart attacks; students and teachers; parents and children; etc.).

We must create a system where staff retention is a priority. So many people leave community psychiatry because they burn out and don’t receive support. Patients should leave us because they recover and become independent; we should not leave them.

In addition to medication, individuals with serious mental illnesses need access to decent housing, vocational opportunities, and opportunities for socialization. The clubhouse is the best model for meeting these needs.

Note that Torrey argues that medication is the anchor for psychiatric treatment. Others disagree. I think it depends on the person and situation.

Clubhouses don’t receive the attention they should. They’re inspiring. Fountain House in New York City is the original clubhouse. One of the primary arguments against clubhouses is that they do not foster integration with people who don’t have psychiatric conditions. We all, however, are free to choose who we want to spend our time with and people with psychiatric conditions are no different. If they want to spend time at the clubhouse, they can. If they don’t, they won’t.

To protect vulnerable mentally ill individuals living in nursing homes and board-and-care homes, there must be periodic, unannounced inspections by an independent state agency. Evaluations and corrective actions must be made public.

I agree.

My work has not brought me into nursing homes and adult family homes (what “board-and-care homes” are called here in Washington State). Torrey presents heartbreaking anecdotes and data about the treatment people did not receive and the abuses they experienced in these facilities. (They mirror reports that came out of some state hospitals in the past.)

Unfortunately, people with psychiatric conditions generally don’t pull at heartstrings the way kids with cancer do. I worry that, given the relative apathy to the number and conditions of people who are homeless, the public may not have any reaction upon learning what happens in adult family homes.

For-profit funding of public mental illness services has been tried and does not work.

I agree.

Torrey and I share the same perspective: If the organization’s goal is to make a profit, money will always trump patient care. People with significant psychiatric conditions will somehow exit the system[3. And by “exit the system”, I mean patients are actively pushed out, not let back in, or made to jump through hoops that they cannot get through in order to receive services.] because they often require resources—time, money, energy—that are antithetical to saving or earning money.

This is why I am biased against for-profit correctional systems.

In selected cases, psychiatric information on mentally ill individuals who have a history of dangerousness should be made available to law enforcement personnel, because they are now the frontline mental health workers.

This point is tied to Torrey’s arguments that people with severe mental illnesses are dangerous. To Torrey’s credit, he does state that people with psychiatric conditions are vulnerable and are often victims of violence, but he spends a lot more time discussing the murders that people with psychiatric conditions have committed.

There are obvious privacy concerns about this. Are police officers familiar with HIPAA? How else might law enforcement officers use this information?

The single biggest problem with the present anarchic system of mental illness services is that nobody is accountable. It will be necessary to assign responsibility to a single level of government, and to then hold such individuals accountable, before any improvement can occur.

Torrey makes it clear that the federal government should not be the responsible party. I agree with that.

While I understand the Torrey’s sentiment, it is much easier said than done. The “mental illness treatment system” now spans multiple domains: the legal system, emergency departments, medical clinics, homeless shelters, law enforcement, mental “health” centers, hospitals, etc. Working with all these groups and aligning efforts to a set of goals will require significant culture change.

If you made it this far in the post, let me conclude by saying that, even if you don’t agree with Torrey’s thesis, this book is still an engaging and thoughtful read. I will confess that I began to feel hopeless and overwhelmed as he laid out all the failures of the system. However, he did finish the book with compelling solutions and highlighted that we can’t give up. This is not easy work, but it is meaningful work, and there is value both to individuals and the community if we take care of the vulnerable people in our lives.

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Education Funding Homelessness Medicine Observations Policy Reading Systems

Thoughts on Stuff.

Recent things I have read that I have found interesting, curious, or vexing:

The Social Security Administration maintains a “compassionate allowances” list, which is a list of “medical conditions [that] are so serious that their conditions obviously meet disability standards”.[1. You can learn more about how diseases make it on to the “compassionate allowances” list here.] Cancers, genetic conditions, and diseases still known by eponyms make the list. (Medical types: This is your list of zebras, not horses.)

“Can you receive SSI (Supplemental Security Income)[2. The Social Security Administration mails a check of about $721 once a month to individuals who receive SSI. To receive SSI, you must have “limited income and resources” AND you must be disabled, blind, or age 65 and older. I got lost while digging through all the subsections, so I don’t know what the “limited” income is. “The limit for countable resources is $2,000 for an individual and $3,000 for a couple.”] while living in a public shelter for the homeless?” the Social Security Administration asks.

Answer: “Yes. You can receive up to the maximum SSI benefit payable in your State while living in a public shelter for up to 6 months out of any 9 month period.” (Emphasis mine.)

While it is true that most people are in the shelter system for less than three months, is it possible that some people who receive SSI will need more help over a longer period of time to get out of the system?

If someone must stay in a shelter, that usually means that he can’t pay rent. Most employers prefer to hire employees who have actual home addresses. No job means no income. No income means difficulties finding affordable housing. And it is mighty difficult to pay for housing and food with only $721 a month.

Psychiatry has little to offer in the realm of prevention.[3. Some would also argue that psychiatry has little to offer in the realm of treatment. In moments of frustration, I agree.] We have no medications to prevent schizophrenia, though omega-3 fatty acids might reduce the likelihood that a youth already showing some signs of psychosis will develop “full blown” psychosis. (Researchers are putting efforts into preventing psychosis, which is exciting.) Most people don’t go to therapy prior to experiencing uncomfortable and distressing emotions.

The WHO has a paper about social determinants of mental health that cover the entire lifespan. Frequent themes in the paper include providing education for women; attending to the mental health of mothers before, during, and after pregnancy; reducing poverty; and providing support to people in school and in work. The prevention of and reductions in psychiatric symptoms were not due to medical interventions.

Incorporating mental health into daily living helps people stay well and develop the resiliency to deal with crap. It’s not a separate thing. We know that people who have had adverse childhood experiences are more likely to have psychiatric and medical problems as adults. Exercise, spending time with friends and family, maintaining stable relationships, eating nutritious foods, learning about stuff, finding value in work and hobbies, avoiding conflict and trauma—all of these activities are useful in preventing major psychiatric conditions.

How many of us in psychiatry focus on these social determinants in our daily work? How have we let ourselves become “prescribers”? Can we change that so that we “prescribe” education and activity more often, and only prescribe medications in the most severe circumstances?[4. This is easier said than done, given that we cannot control the behavior of other people or systems. I also detest the word “prescriber”. That’ll be another post.]

Someone pointed me to this article with the polarizing title: Bad Managers Talk, Good Managers Write. The author argues:

When managers write, you create work product — white papers, product requirement documents, FAQs, presentations — that lasts and is accessible to everyone in the organization. From marketing to sales to QA to engineering, everyone has a document off which they can work and consult.

The upshot is that the manager also takes public responsibility for what happens when the rest of the team executes on the point of view taken by the documents. That ratchets up accountability through the organization.

This is also the benefit of keeping a blog. You create a body of work that people can read, refer to, and learn from. More importantly, regardless of your work (whether it is your formal profession or what you do “on the side”), it gives you the opportunity to reflect on things that matter to you, clarify your thinking, express your ideas, and connect with interesting people, including yourself.

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Education Homelessness Lessons Medicine Nonfiction Policy Reflection Systems

Involuntary Commitment (VII).

This post is overdue by one year! It may help to review the third scenario and a primer on involuntary commitment before reading on.

Why the delay? Because I still wrestle with the question at the end of this post.

Recall in the third scenario the man, described as a chronic inebriate, who frequently tried to kill himself while intoxicated. He recently had slapped a woman in a laundromat and had thrown a can of soda at outreach workers. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

While intoxicated, he has said that he wants to kill himself and we know that he has, in fact, harmed other people: He slapped a woman in the laundromat and he threw a can of soda at some outreach workers. While these may be minor insults in the grand scheme of things, they still suggest that he is disinhibited enough potentially harm someone.

2. How imminent is this risk of harm to self or others?

Probably imminent. Since he is frequently intoxicated, he is frequently disinhibited.

3. Are these behaviors due to a psychiatric condition?

Maybe.

Is an alcohol use disorder a psychiatric condition?

Think about your answer again.

Though “alcohol use disorder” is listed as a condition in DSM-5, some would argue that it is not a psychiatric condition. They would say that it is a choice. They would also argue that the mental disturbance that comes from alcohol use is temporary while “true” psychiatric conditions do not have the same cause-and-effect phenomena that we often see with alcohol.

However, we also know that this man has reported auditory hallucinations in the past and, regardless if his alcohol use is a psychiatric condition or not, his intoxication is clearly affecting his ability to function.

At least that is how I formulated it.

Related: Will hospitalization help treat the underlying psychiatric condition?

Possibly. The likelihood that he can become intoxicated with alcohol in the hospital is very low (but not impossible).

What actually happened?

The man was going around in circles from emergency room to street to jail. The police wanted him admitted to the hospital because the only time the police weren’t picking him up was when he was sober, which was when he was in the hospital. The outreach team had housing for him (he could have moved in tomorrow!), but he was too intoxicated to accept the invitations.

There was a big meeting and we concocted a big plan: The outreach team would find and talk with the man in the park in five days at 11am. He would likely be intoxicated and belligerent by then. The police would meet us there. The police would help transport the man to the hospital on an involuntary order. The emergency department staff would admit him to the hospital, whether he agreed to or not. Once he received treatment in the hospital, he would be discharged into his own apartment, with hopes that he would stay off the streets and away from alcohol.

What could go wrong?

On the appointed day, we found him in the park.

“Hey hey hey,” he said, putting his arm around the outreach worker, a goofy grin on his face. He offered the 40-ounce can of beer to us. “It’s the first one. Half full. I’m an optimist.” He laughed.

My heart was starting to sink: Even though he slapped a woman and threw a can of soda at someone less than a week ago, he wasn’t doing anything right now that would warrant an involuntary hospitalization.

But the show must go on, right? Multiple people and systems were involved. We had a big plan. And going through with the plan would be in his best interests, right?

Right?

“So,” the outreach worker started, “what do you think about going to the hospital with us?”

He laughed. “I don’t need to go to the hospital. I’m fine.”

“The doctors can check your health, make sure everything is okay….”

“Naw, don’t need it. I feel fine.”

Indeed. He was buzzed, but that wasn’t a reason to go to the hospital.

He looked over our shoulders, smiled, and shouted, “HEY!”

Behind us were four men with broad shoulders and thick legs. We all recognized them as police officers, though they were wearing casual clothes. They nodded at us.

“Wanna go to that bar with me?” the man asked, pointing to the brick building down the street.

“Sure!” the police said, chuckling. “It’s 11am.”

The outreach worker and I stood by our car and watched them disappear into the bar. We said nothing. Still nothing had happened that would warrant hospitalization, voluntary or not.

Several minutes later, the police officers and the man emerged from the bar. The man was singing:

Hello!
Is it me you’re looking for?
’cause I wonder where you are
And I wonder what you do
Are you somewhere feeling lonely?
Or is someone loving you?

The officers started laughing. Everyone was having a good time.

The police led the man to a squad car and opened the back door.

“We’re going to the hospital.”

“F@ck no,” the man said, smiling, having no idea what was happening. My heart sank further.

“Get into the car.”

“No!”

“Look, get into the car—”

—and that’s when he spit at a police officer.

WHAM! It happened so fast that I couldn’t believe what happened. They threw him against the hood of the police car. Two officers pinned his arms down. The other two looked ready to strike him.

I wasn’t the only one who noticed. Pedestrians began to rubberneck. Some young men began to call, “What did he do? Why you doing that?”

“It’s none of your business. Keep walking. There’s nothing to see here,” a police officer barked.

“No, that ain’t right. Why did you do that?”

A woman with flowers in her grey hair and a flowing peasant dress around her thin frame approached.

“That’s police brutality, that’s what. We need to get rid of the cops.”

In the meantime, the police officers had handcuffed the man—for what? for what?—and placed a mesh bag over his head so that if he tried to spit again, the netting would catch it.[1. This mesh bag is called a “spit sack”.] They pushed him into the back of the car and closed the door.

The crowd on the sidewalk grew. Close to three dozen people started to shout and chant at the police officers.

The outreach worker and I got into our car. What was happening?

The ambulance the police had called arrived. A paramedic got out and, hands on his hips, talked with one of the police officers. His brow was furrowed and he was frowning. The officer shrugged, then pointed to our car.

The paramedic walked over and knocked on my window. I rolled it down.

“What did this man do? Why are we taking him to the hospital? Did he actually do anything that warrants an involuntary transport?”

My cheeks burned.

“No.”

The paramedic[2. God bless this paramedic. We need people like him to ask these questions.] glared at me. He then turned around and walked away.

The police and paramedics moved him from the back of the police car into the ambulance while the crowd continued to bristle. The ambulance honked as it tried to weave through the crowd.

After the police drove away, the crowd dispersed.

The outreach worker and I sat in our car in silence. My cheeks were still burning.

He was in the hospital for about two weeks. The first three days were against his will. He agreed to stay in the hospital for the remaining 11 days.

The outreach worker met the man when he was discharged from the hospital to escort him to his apartment. He attended AA meetings four days a week. He took his two medications every night. He saw his counselor every week.

He avoided the park. The police started calling our office: “We never see him anymore. Do you know what happened?”

I never saw the man again, though heard occasional updates from his psychiatrist. The man didn’t drink any alcohol for nearly a year. When he did slip, he asked to go to the hospital. The police never got involved.

Even now, I still ask myself, “Did we do the right thing?”