OUR GENERATION

What I've learned on the way to a career

By Maria Manriquez Gilpin, MD

In the 2 years since I completed my ob/gyn training, I've had four jobs in three different practice settings in three different cities. I'm now headed back where I started geographically, combining the practice of obstetrics and gynecology with raising a rambunctious 7-year-old boy and a 9-year-old Hillary Duff-wannabe as a single parent. Let me explain how I made—or didn't make—all my transitions and perhaps you can learn from my experience.

The saga began in Phoenix, when my then-husband of 10 years, who is also an ob/gyn, and I decided that if we were ever to get out of the heat and have the much-less-harried lifestyle that a small community in California could offer, it would be when I finished training. We were recruited by a hospital in Northern California to open a private practice in a small town south of San Jose.

The town council, city health foundation board, and the director of the local IPA convinced us that moving and starting a practice in the small Northern California town were a sure thing. But during the first month, we had virtually no patients and by month 10, only enough patients to sustain a part-time, one-physician practice. We couldn't even cover our overhead, let alone pay ourselves salaries!

The ensuing depression and marital stress marked the beginning of the end of my marriage. My husband and I separated in June 2003. After the separation he took a job in Phoenix and I took the job we had both planned to go to in Central California. Once my spouse and I separated, my employer there worried about whether he'd made a wise investment in me, and his anxiety level grew when we decided to have the children return to the parochial school they had attended in Phoenix. My employer began changing our original agreements and pressed me hard for a long-term commitment. (For example, he originally agreed to pay $6,000 for tail coverage, but would only fulfill that commitment if I signed a contract stating I would stay 5 years.) When I gave 3 months' notice of my intention to seek employment elsewhere—which I did as a courtesy—I was asked to leave immediately. That translated into 2 months of unemployment, as it takes at least that long to get through credentialing and be granted privileges.

I next sought work in Phoenix and even considered returning to the original practice if I could obtain extension in support. My ex-spouse discouraged me from returning to Phoenix because he thought reconciliation was impossible and the hospital was not willing to extend the support. Since November 2003, I've been with a multispecialty group in San Jose, where I worked with outstanding clinicians who became my friends. I loved my work; obstetrics and gynecology is a wonderful profession and I take great pride in my ability to care for my patients. But it's time for me to go back to Phoenix, which is returning home and not giving in to failure, as I'd often previously thought.

What could I have done differently? I am certain my "ex" would agree that it was altogether too risky for us both to take a job with unstable income. In retrospect, one of us should have taken a salaried position and used that income to support the household while the other built a practice. Once the practice was flourishing, the salaried partner could have transitioned into it. Starting a practice from the ground up takes commitment, exceptional marketing skills, and obsessive business management. None of these skills are part of ob/gyn training, and that alone makes the risk for failure quite real.

The second move, to Central California, was borne of desperation. I committed a cardinal sin: accepting a job without a contract and with vague commitments and unclear expectations. Alas, another lesson learned.

Finally, after considering a job in Arizona, I serendipitously found the "right" position in San Jose. It was outstanding because it offered one office, two associates, one hospital, a 4-day workweek, and plenty of patients. After my experience in the little town in Northern California, I solemnly swear never to complain that I have too many patients! There was only one thing missing: my children, my family, the grounding pad that makes many of us able to care compassionately and effectively for our patients. At the end of the day, those adorable faces can light your world.

As I look to my future, spending quality time with my children, family, and friends will be paramount. I am also excited about my new job with the Phoenix Integrated Residency in Obstetrics and Gynecology. I will have the opportunity to bring my past experiences with the Residency Review Committee and private practice to teaching residents and promoting quality graduate education.

It may seem trite, but like many people I've found that all experiences—good or bad—teach invaluable lessons. The three key things I've learned in the past 2 years on my way to a career are:

1. Change is unavoidable.

2. Limbo is a state of mind, not a disease.

3. At the end of the day, how you touch a human heart is what matters.

I recently read The Five People You Meet In Heaven by Mitch Albom. It made me appreciate the fact that everyone we meet—and as ob/gyns, treat—can alter our lives. The book also convinced me that someday, everything I've gone through or will go through will make perfect sense.

"Our Generation" offers real-world solutions to problems faced by ob/gyns new to practice. Written by young readers for young readers, each column sketches out a specific problem and offers practical "street-smart" advice. Columnists Steven J. Fleischman, MD (sfleischman@snet.net), Elizabeth Lapeyre, MD (Lizlapeyre@yahoo.com), Maria Manriquez Gilpin, MD (mmgilpin@yahoo.com), and Editorial Board Advisor Nanette Santoro, MD (glicktoro@aol.com), welcome your questions, comments, and ideas. Let them know how life is going in the trenches.

DR. GILPIN is the Immediate Past Resident Representative to the Accreditation Council for Graduate Medical Education Residency Review Committee for Obstetrics and Gynecology. She is on faculty at the Phoenix Integrated Residency for Obstetrics and Gynecology in Phoenix, Ariz.

Starting up or starting over? Here's how to avoid mistakes

Certain basic precautions might have prevented some of Dr. Gilpin's difficulties.

By Barbara Weiss

Anyone can have a false start," says Judy Bee, of Practice Performance Group, La Jolla, Calif. But Dr. Gilpin's first practice disaster might have been avoided if she and her husband had asked certain questions. A hospital wouldn't be recruiting physicians if it didn't have a need, Bee explains, but it might not be completely candid about that need. (For example, it might simply want to replace uncooperative physicians with more compliant ones.) Furthermore, hospital executives may not even realize that satisfied ob/gyn patients don't switch to new, unknown doctors just because they arrive on the scene.

Before you move to a new area, Bee recommends asking yourself and everyone you encounter there:

• Why do they need me and what problem do I solve?

• How long have they been looking for a new physician?

• Who serves the patients now, and how do I contact them?

• Who will I be on call with, and what are their telephone numbers?

Keith Borglum, of Professional Management and Marketing, Santa Rosa, Calif., suggests that you "mystery shop" competing practices in the area to find out patient wait-times for a routine visit. "If practices are booked 2 weeks or more, there's plenty of room for another practice," Borglum says. "On the other hand, if most can see a patient within a week, you might want to reject that location."

Judy Bee recommends that ob/gyns being recruited by a host practice or hospital ask to have their salaries underwritten for the first 2 years. "That's because some ob fees aren't paid until after the delivery, so the cash flow is delayed even if a new doctor gets busy quickly. Besides, new grads don't do much surgery initially."

Our consultants disagreed with Dr. Gilpin that starting an ob/gyn practice takes "exceptional marketing skills and obsessive business management." Borglum says "you should have a well-researched and well- organized plan," but there's no need to reinvent the wheel or master a process that you won't need again, and it's usually more efficient to outsource these tasks. You can get books on starting and running a practice at www.medicalbookstore.com and experienced consultants are available through the National Association of Healthcare Consultants ( www.healthcon.org ) and the AMA's ConsultingLink Network at ( www.AMAConsultingLink.com ). Consultants often offer 1-day intensive start-up consults for $1,000 to $2,000, and monthly support for less than the price of a receptionist. (If after two complete month-end reports, your charges, collections, accounts receivables, and overhead numbers all balance, you'll need the consultant's services far less.)

Borglum recommends looking into purchasing a practice, which he terms "an excellent investment at the right price. "Because there's a limited field of buyers, medical practices sell for proportionately less than other ongoing businesses, such as restaurants, and the value of many practices can be earned back by the buyer within a year," he says. Specialty medical lenders will lend up to $200,000 to physicians—even those with big medical school loans—as long as the numbers make sense.

Before accepting a job

As Dr. Gilpin learned, to her sorrow, the terms of employment should always be spelled out in writing. In fact, her employers' reaction to the news she was leaving—firing her—is pretty standard practice. Her mistake was in not having a contract that spelled out the conditions under which she could be terminated and how much notice was necessary—for example, 60 days. Had that been the case, the practice would have had to pay her another 2 months' salary.

Borglum suggests you investigate a potential employer carefully, particularly if it's a smaller practice (fewer than 20 physicians). Try to arrange for 30-minute interviews with physicians, an hour with the administrator/manager, and 15 minutes with key staffers. Ask if there's much staff turnover and why the position is vacant. Ask how a new physician will be marketed and introduced to the lay and medical communities. And ask about current or anticipated litigation. Have a CPA or consultant review the practice financial reports. And ask for the terms of employment to be spelled out in writing (see "Get it in writing").

Perhaps even more important, as Dr. Gilpin's recent history proves, you need to define clear career goals for yourself. "Taking a job" rather than "advancing a career" is seldom likely to work out, Judy Bee advises. "A better choice for Dr. Gilpin might have been to work as a locum tenens or at Planned Parenthood or some other community health agency while she decided where she and her family would put down roots. The need to consider two ob/gyn careers in this family made the planning process more difficult—and all the more necessary."

Ironically, Dr. Gilpin and her husband needed this logical thought process most when they were being buffeted by the emotional storms of a disintegrating marriage. Early post-residency is a stressful time if you've been trained in academics but not the financial aspects of practice, says John-Henry Pfifferling, PhD, of the Center for Professional Well-Being, Durham, NC ( www.cpwb.org ). And when a husband and wife work together, "everything that's involved in the practice comes home." If one or both are perfectionists, conversation at home may focus exclusively on criticism and defense.

"We often ask married doctors opening a practice to have at least one session with a counselor beforehand to get a sense of how they'll handle the problems," Pfifferling says, "and to know what warning signs to look for." They'll want to be sure that their goals are in line, and that potentially divisive issues such as childcare and first call have been worked out fairly in advance. He advises them to meet together regularly to assess how they're meeting their goals.

Bee recommends that all young physicians try to clarify their goals and think through their priorities concerning the demands of relationships and families. "Even bad changes need not be disasters," she concludes, "if they help you establish your goals."

MS. WEISS is the former Editor of Medical Economics, OB/GYN Edition.

Get it in writing

Here are the basic clauses your contract should have:

Compensation. What is included in your pay (patient services in the office and hospital) and what is excluded (publishing revenues, training stipends from drug companies, directorships). You're entitled to keep the revenue from anything that's excluded, so if you plan to moonlight in the next town, be sure that's specifically excluded. Conditions for bonuses and incentives should also be spelled out, as well as who has a right to audit the books. (If you're paid 50% of collections minus overhead, you want to know what collections and overhead amount to. And you want to make sure that the boss's car isn't included in the overhead.)

Conditions for terminations. Under what conditions can you be terminated and how much notice must you be given? Some contracts may ask you to sign a restrictive covenant, although these are virtually unenforceable in many areas.

Expense allocations. Be sure you know which of your expenses are covered, including malpractice and health insurance. Some practices may allow you to deduct certain expenses, such as a car, through the corporation.

Continuing medical education time and expense.

Contract term (in years).

Dispute procedures/arbitration.

Fringe benefits. Are you covered for disability, health, and life insurance? Do you have a pension or profit-sharing plan?

A hold-harmless clause. Has the practice signed contracts with HMOs that state that the practice will hold the plan harmless for wrongful denial of care? These are much less common than they used to be, but you don't want to be on the hook for defending your employer and yourself, especially in ob/gyn.

Sick/family leave.

Malpractice insurance. Be sure to check for tail coverage.

Medical records ownership.

Performance evaluation process.

Reimbursement for relocation costs.

Standards of practice.

Vacation and sabbatical.

Practice purchasing rights or partnership/corporation buy-in and pay-out. You may want to know if you'll be given an opportunity to be an owner, and if so, under what terms. Can you become a full partner in the group? What obligations will you have if the older doctors retire? (Or, if some ob/gyns decide to give up obstetrics?) All this should be spelled out.

—Keith Borglum

Maria Gilpin. Our Generation: What I’ve learned on the way to a career.

Contemporary Ob/Gyn

Jul. 1, 2004;49:40-43.