Category: Lessons

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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.

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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.

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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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Lessons Nonfiction NYC Observations Reflection

Living in New York, or Assertiveness Training.

Over three years have passed since I moved out of New York—or returned to Seattle, however you want to look at it. I have had the good fortune to visit New York every year since my departure, though I was unable to last year due to my mother’s illness.

Whenever people ask me about my time in New York, I usually say something like, “I’m so thankful that I had the chance to live there, but I ultimately found it too overstimulating.” Sometimes I comment how I found myself laughing when I realized the number of people who seemed to take everything, including themselves, so seriously. I didn’t laugh because I found their behaviors funny; I often didn’t know how else to react.

When I was an intern in Seattle, one of the fellows told me about the year he spent in Boston earning an Master’s degree in public health. “Living on the East Coast is like going through assertiveness training,” he quipped.

Indeed, I found my three years in New York to be a course in assertiveness training. This training did not occur because “people are rude in New York”. To be clear, there are rude people in New York, but not more so than anywhere else.

People learn to assert themselves in New York City because of the constant crush of people and what seems like scarce resources. (“Resources” isn’t limited only to money; I refer also to time, attention, and space.) If you don’t assert yourself, people overlook you. And I’m not even talking about people overlooking you for promotions, relationships, or praise. I’m talking about crowds overlooking you while you try to get on a subway car[1. Here are photos of men taking up too much space on the train. Many of the photos feature the New York City subway.], taxi drivers overlooking you as they race down the avenues, or the guys at the pizza counter overlooking you when you’re trying to order a slice.

You learn to change the way you walk, the way you hold yourself, the way your form occupies space. You learn to arrange your body and face to announce, “I am here.” You don’t send that message because you want to be the center of attention; you just want to get stuff done.[2. Because you learn how to adjust your body and face to make your presence known and felt, you also learn how to turn all that off. Sometimes you want to disappear into the crowd; you just want to watch what is happening around you without having to take part.]

You learn to speak up. Speaking up doesn’t mean speaking more; you learn how to get enough attention for enough time to say what you need to say. You learn that if you don’t speak up, people

  1. may not realize you are there
  2. may not realize that you have something useful or helpful to offer
  3. may develop wrong opinions about you, what you think, or what you’re about

You learn to speak up and make your presence known because you witness someone else speak up and advocate for you. You pay that forward and notice that, for whatever reason, that karmic system works.

You also learn to assert yourself because sometimes you get attention you don’t want. There are all the irritating men who catcall you[3. I am an N of 1, but men in New York catcalled me way more than men in any other city I have lived in. That video resonated with me.], the taxis that trail you as you walk on the sidewalk, and the disgruntled people you happened to interact with at the wrong time. You learn to ignore the unwanted attention without showing discomfort or fear on your face. You arrange your body and face to announce, “I am here, but not for you.”

You learn that people respond to you—favorably!—when you assert yourself. You learn that when you speak up and deliver your message in an envelope of good manners, people often change their behavior. You learn who respects you. You also learn that one of the best ways to show respect to others is to tell them what you’re thinking and feeling. You learn that they can handle it. You also learn that you can handle it, too.

I remain grateful to New York for teaching me how to sharpen my assertiveness skills. I’ll be visiting the great city soon and trust that I will have no choice but to review the coursework.

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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?”