Kylie N. Jungles, MD (Host): Hello and welcome to the Special FIT episode of Allergy Talk, a podcast by the American College of Allergy, Asthma and Immunology. This is part two of our job search series. If you caught episode one, we talked about the ins and outs of starting the job search process and finding a practice setting that is a good fit, no pun intended for you.

If you haven't listened to part one, be sure to go back and check it out. Today we're diving into what happens after you've landed the job. I'm Kylie Jungles, one of your co-hosts today, and I'm currently the Senior National FIT Representative for the College and the head of the FIT Committee. As a soon to be fellowship graduate, I was in your shoes not too long ago as I was beginning the job search. I'll actually be graduating from my fellowship at Rush University Medical Center in Chicago in just a few weeks before heading out to upstate New York to join a private practice group with an attending that I actually met at the College meeting.

Amber N. Hardeman, MD, MPH, MBA (Host): Thanks, Kylie. And I'm Amber Hardeman, the National Junior FIT Representative to the College. I'm currently a first year fellow and I'm deep in the interview process currently. Thanks again for tuning in. If you missed episode one, we did cover how to navigate the job search, choose the right practice setting and prepare for interviews.

Kylie N. Jungles, MD (Host): And we're so excited to welcome back our expert guest, Dr. Melinda Rathkopf. She's a seasoned allergist and an incredible mentor for FITs nationwide. Thanks for joining us.

Amber N. Hardeman, MD, MPH, MBA (Host): Dr. Rathkopf, we're so glad to have you back. Can you reintroduce yourself briefly for anyone new who might be joining us today?

Melinda M. Rathkopf, MD, MBA: Of course, and thank you for having me back and please call me Melinda. So I'm Dr. Melinda Rathkopf. I'm an Associate Professor at Emory University School of Medicine. I'm Medical Director of the Allergy Clinic at Children's Healthcare of Atlanta, and I'm core faculty of our Allergy Immunology fellowship training program here.

I've worked in military settings, private practice setting, and now I'm in an academic setting. I love working with fellows and helping them transition successfully into practice. I've been working at the College for many years and I'm very active with the Practice Management Committee and Advocacy Council. Those are my two passions, so I'm excited to be back with y'all today.

Kylie N. Jungles, MD (Host): Thank you so much for being with us. We really appreciate your expert advice. So on our last episode, we talked about interviewing, finding the job. So let's start with talking about what happens if you're lucky enough to have multiple job offers. In some ways it's exciting, but it can also feel overwhelming.

Amber N. Hardeman, MD, MPH, MBA (Host): Yeah, agreed. What are the top three things, Melinda, that you think that fellows should consider when narrowing down our job offers to find the best fit?

Melinda M. Rathkopf, MD, MBA: First, make sure the job you're looking at is one where you can see yourself working and you can see yourself thriving there. You know, you're going to spend a lot of time at work in the future. So as we discussed in part one, really trust your gut. Don't seriously entertain an offer from a job that you don't see yourself accepting.

It's a waste of your time. It's a waste of their time. Politely decline and move on. Second, look at the long game. What would working at that practice look like in a year, maybe five years or even longer? And third are the people, whether it's the physician, the other providers, the employees, do they seem happy?

You know, not everyone's happy every day, and it's not your job's job to make you happy. That's your job. But can they be happy in the job? Are they happy there, or is there a lot of turnover? How does the job feel and how do you think you would feel if you were there?

Kylie N. Jungles, MD (Host): Those are all really great tips. During the interview day itself, it might be overwhelming to kind of take everything in. I was wondering is it common or even appropriate to ask for a second look day at a practice you're seriously considering?

Melinda M. Rathkopf, MD, MBA: I think this is really important, you know, if you're able to do that. One, I think it shows them you're seriously interested, but you're also taking the offer seriously. At this point you've likely talked to and looked into multiple jobs. Even the most organized person can get details confused.

You know, I, uh mentioned, if you've ever looked at houses before, after a couple days of house hunting, everything starts to look the same. So you want to make sure you remember correctly, details of each job. So if you are seriously considering an offer, ask if you can visit again, especially if your interview was virtual, I definitely would not take an offer with a job until you actually see it in person.

See if you can spend a half day or more there. You know, maybe it can be combined with a house hunting trip or another trip to get to know the area. You can talk with the staff, you can shadow with one of the physicians, and again, you know, can you see yourself being fulfilled here and working with this group?

And how are the group dynamics? I had an interesting interview at one place where my interaction with the physician was great, but I just didn't feel comfortable in the group dynamics with the rest of the office and thought, I'm not sure that this would change if I came here. And then also look at the patients.

Are the patients happy? Look at the patients both as they come in and as they leave.

Amber N. Hardeman, MD, MPH, MBA (Host): That makes great sense that we should look into that. And also, you know, we're looking at all of these different practices. How can us as fellows professionally communicate that we're considering multiple offers, or that we're not any longer interested in a position, but without burning any bridges?

Melinda M. Rathkopf, MD, MBA: The first thing to remember is that all the doctors you're communicating with, they were once in your shoes. So just be open and honest, but also be courteous about their expectations. Let them know you have other offers and other visits, that you want to be sure you're making the most informed choice.

I had been offered an amazing job offer, the one I eventually took in Alaska, but I still had some interviews scheduled that I felt I needed to check out, and they were quite accommodating in letting me do those additional interviews before giving them an answer. If they make you an offer, ask what their timeline is for your decision and then respect that timeline.

Be sure not to ghost anyone. Be respectful. If you need to push the timeline a little, be open and honest about that and ask if you can. Also, I would ask about their preferred method of communication and use it. Some would consider email to be the best option, whereas many of us don't get to our emails as often as we like.

Some may prefer texting, but some may consider that to be too informal. Being open and honest is always the best policy. You may be communicating with an office manager, but always give them the same courtesy and respect you would give the head position, who's making the hiring decision.

Kylie N. Jungles, MD (Host): That's really helpful advice. I think often it's a lot to juggle when we're in the middle of fellowship, seeing patients in clinic and also navigating this job search process. So it's great advice on how we can kind of coordinate everything, especially with the practices we're talking to. So once we have an offer, the next step is contracts.

It can often be nerve wracking. I felt very stressed receiving my first contract and not quite knowing where to start.

Amber N. Hardeman, MD, MPH, MBA (Host): Totally agree. So Melinda, what do you think are the top elements of a contract that fellows should really focus on?

Melinda M. Rathkopf, MD, MBA: Contracts are very daunting, and especially if there's a lot of legal speak. I got my MBA and had to take a healthcare law class. And I still don't understand legal speak, right? So these contracts generally involve a section on compensation, a section on benefits, work expectation and termination clauses.

But again, start with you. Some physicians prioritize paid time off and the call schedule. Some may be more concerned with benefits packages and the compensation structure. Not every part of a contract is negotiable and negotiation requires compromise on both sides to achieve desired outcomes. You know, you really want to prioritize the most critical aspects of the contract for you.

So again, starting with you, as we mentioned in part one, and knowing what is your top priority. Be prepared for compromises on less important contract terms. That really shows you're a team player and you're willing to work together and compromise. Establish clear goals that a realistic understanding of what the employer can offer is essential for satisfaction.

You know, you want to take time to determine what parts of the contract are more important to your life before heading into that conversation with your potential future employer. That tip comes out of the FIT toolkit mentioned in episode one on the College website. There's a good article there on negotiating a good offer into a great offer.

This is really a must read when you're at this step. There's also a link to a good AMA article on understanding physician employment contracts, so I strongly recommend you check out those resources.

Kylie N. Jungles, MD (Host): Thank you so much for all those resources. It's very helpful. So the next thing to think about too is compensation. You know, as fellows, residents, we had a set salary. We didn't have any kind of say in that. So can you help us demystify the different compensation models? We have base salaries versus productivity models, cash pay, RVUs, and also benefits.

Because now we have a little bit of a say in that. What are some things that you could tell us about that structure?

Melinda M. Rathkopf, MD, MBA: I'm chuckling a little because what just popped into my head is one of my favorite, TikTok videos on what physicians learn about the US healthcare system in medical school, which we all know how much that was, right? But when asked with the question of, do you even know how physicians get paid, the person in the video says.

I do physician stuff and someone pays me. So, you really need to know how we get paid. What are these different models? And you know, honestly, this could be a full webinar or a podcast topic on its own. And I think it has been. So salary and compensation packages are a central component of your employment contract. Physicians may be offered a base salary.

So that means what you're going in at, what you're going to get paid regardless. You may be offered some productivity based pay, so meaning you get paid based on what you see or you eat what you kill. Right? And, this could be RVU based, or it can be a combination of both. There may be salary matching programs.

So I had the benefit when I first moved up to Alaska that the local hospital gave a salary matching contract to me for my first few months as I was starting to see patients and get collections. So in addition to base salary, be sure to solidify details on bonuses and profit sharing. So let's kind of define these a little further.

So a brief explanation on some of these. So, your base salary, this is generally a fixed amount of money that you receive on a regular basis regardless of the number of patients seen or procedures performed. It provides financial stability, predictability as the income does not fluctuate with changes in the workload or the patient volume.

You could have productivity base such as RVU based compensation. This model ties your compensation to your productivity, often measured in terms of relative value, units or RVUs. These are a standard metric used in medicine to quantify the value of services provided by a physician based on factors such as time involved, skill involved, and intensity.

Under this model, the physician's income can increase with higher patient volumes and more complex patients, more complex procedures. So it incentivizes efficiency and productivity. And then some compensation models, often a blend of this, maybe a base salary with a productivity based bonuses based on RVUs.

This allows the best of both worlds with a stable income with the base salary, but also offering the potential for additional earnings based on productivity. And this is probably one of the most common models I see out there. It aims to balance this financial security with incentives for increased performance and efficiency.

If your compensation is going to be even only partially based on RVUs, I recommend you fully understand what RVUs are. Again, there's a College toolkit on this. That's the take home lesson here. Right? And we just updated it recently on RVUs. There can be a large variation in the number of work RVUs that are assigned to common allergy services, and they can change every year.

So several allergy services such as skin testing, which is a 95004 or patch testing, have low or no work RVUs associated with them. The actual reading of the skin test and the outcome is tied to the procedure and it doesn't give you additional RVUs. So if your compensation is work RVU based, consider how you're going to be compensated for these services that don't have much work RVU. This is also true with allergy injections. You can have a huge allergy clinic, but those actual injections don't have associated work RVU, but they definitely have revenue associated with them. So try to find out how other allergists and non allergists in the organization and in your geographic area are being compensated based on work RVUs.

It's not uncommon for allergists to negotiate a higher average work RVU rate to compensate for the lack of work RVUs for many of those allergy codes, like I mentioned, our testing codes, injection codes, and even administration of biologics that may not have work RVU, but bring in compensation. So this is covered in detail in this RVU toolkit as well as information on allergist compensation.

Through the, MGMA a survey goes out every year to allergists that looks at compensation ranges, different areas and different settings, and it's updated annually. So be sure to check that out on the College website.

Amber N. Hardeman, MD, MPH, MBA (Host): Wow, that's definitely a lot more complex than the way that we get paid in residency or even in fellowship.

Melinda M. Rathkopf, MD, MBA: Where you do the medicine stuff and someone gives you money.

Amber N. Hardeman, MD, MPH, MBA (Host): You're right. Right. So thank you for that crash course and understanding what we should be looking into, but kind of going along with that, we hear a lot about negotiations and the things that we should be negotiating in a contract, but we've never really had experience with that in training.

So for fellows who feel nervous about negotiating, what advice do you have for them to help them advocate for themselves?

Melinda M. Rathkopf, MD, MBA: This is a tough one and I am not the best negotiator out there. You know, most of us want to please people, especially our potential future employers. And for many of us it is not in our nature to negotiate because that's confrontation. And most of us are confrontation averse. So realize the employer is negotiating for what is best for them and for their practice.

You're the only one negotiating for what is best for you. So if you don't do it, nobody will. So look for resources on both the AMA websites and the College websites on this and talk to mentors. See if you can do mock negotiation with a mentor. Practice your negotiations with a friend. Ask for what you want because you just may get it. You definitely won't get it if you don't ask.

Kylie N. Jungles, MD (Host): That's awesome. Thank you so much. So let's stop and take a minute to do a pro tip. What is one thing that every fellow forgets to ask about in a contract, but absolutely should be asking?

Melinda M. Rathkopf, MD, MBA: I would ask about work expectations and get them in writing. What will your clinic day and load look like? Are you expected to see 15 to 18 patients a day, or are you expected to see 25 to 30? Is there call? And what is that call like? Is it primary call where patients have direct access after hours and on the weekend to a physician?

Or is it secondary call, which is what we took in my prior practice where we didn't get direct patient calls, but we were on call for other specialists, for hospitalists and for the ER. Are you expected to do hospital coverage? Many private practices still cover hospitals. Are you expected to teach?

And what if your clinic teaches, but you don't want to? Is that allowed? So while these items are likely to be discussed, you may want to get them in writing, especially if you feel passionate about one of these. The other thing I would see is make sure the long game is addressed. It would be unusual to put all details about future, put partner tracked or something like that in the initial contract.

But there needs to be some discussion of it. So you don't want to, you know, move, start a practice because some of the people sometimes make partner, but there's nothing put into your contract. Is there a potential for a partner track? If so, I would go ahead and talk about it and get some of the basic details in writing.

When is your contract up for renewal? So, you know, some contracts automatically renew unless you purposely cancel them. And then how would you cancel a contract if you needed to? Are you required to get a mediator and go to negotiation or not? When do you get raises? When are you eligible for a raise?

When do you get more vacation time? These are things that seem more automatic in big settings, like big employer based settings or hospital systems or academic settings that may not be as well addressed in private practice.

Amber N. Hardeman, MD, MPH, MBA (Host): So speaking of contracts, let's talk about lawyers. A lot of fellows do wonder, do I really need one to review my contract? Especially, at the end of training when they might be a little bit expensive.

Kylie N. Jungles, MD (Host): Exactly. And if someone does want legal help, how should they go about finding a contract lawyer? I'm assuming they're not the lawyers that we're seeing on the side of the highway when we're driving.

Do they have to be in the same state as the job? Kind of where should you be looking for these lawyers?

Melinda M. Rathkopf, MD, MBA: So the first question, do you need a lawyer? My answer is emphatically yes. Look at how much time you just spent between undergrad, medical school, residency, fellowship, all that time and money you spent on training. Hiring a lawyer is well worth it. Again, you need someone whose main interest is what is best for you, even if that's only because you're paying them for that to be. So, while many large groups or hospital systems, they have lawyers, and they may claim that they have boilerplate contracts and they're not negotiable, but everything is negotiable. An amendment can always be added to a boilerplate contract. In a recent AMA article on employee contracts, rule number one is quote, hire a lawyer.

So, there's a helpful Reach MD podcast where a lawyer discusses best practices for contract negotiations. That's on that College toolkit also. And then there's also firms to help you. So Resolve is a national firm that specializes in physician employment contract, and as a College member, you can actually get a 15% discount on their services.

You can check with your local or state medical society. They may have a list. You can check with professional legal society such as the American Health Lawyers Association or your State's Bar Association. These organizations often have directories of attorneys specializing in healthcare law. You can ask your colleagues or mentors for a personal recommendation.

You can also use online legal directories, like Find Law, AVO or Martindale Hubble. These platforms allow you to search for attorneys by specialty and by location, and they often include reviews and ratings from past clients. If you're affiliated with a hospital or medical group, inquire if they have a list of recommended attorneys, or if they offer legal resources for contract review.

It is generally advisable to work with a contract lawyer who's licensed in the same state as the job that you plan on taking.

Amber N. Hardeman, MD, MPH, MBA (Host): So while we're looking into lawyers or different law firms, are there any red flags in this process that might make us pause?

Melinda M. Rathkopf, MD, MBA: You know, again, going back to as with any service, trust your gut. If it doesn't seem right, get another opinion. I've seen lawyers rip apart contracts like it's a high school English paper they're grading. They get paid by the quarter hour, and so if they spend time editing every line of a contract, they get paid more.

It can actually be an insult to the employer, you know, if the employer had what they thought was a pretty good contract and your lawyer is spending time on nitpicky details, that can kind of be insulting. So really concentrate on the items that are most important. As we discussed above. If the contract you're offered is a complete mess and looks like it was written without a lawyer's help, that would be a red flag for the practice that offered you the contract, in my opinion.

Kylie N. Jungles, MD (Host): That's a helpful outlook to have when we're kind of considering all of this. And then Melinda, what is the ballpark cost for a contract review? How much should we be budgeting for this in our fellowship stipends?

Melinda M. Rathkopf, MD, MBA: Typically lawyers charge in one of the following ways. They could do a flat fee. So many attorneys offer a flat fee for contract review services, and this can range anywhere from a few hundred to a few thousand dollars depending on the complexity of your contract and the level of service provided.

Do you just want a basic review or do you want a detailed analysis and someone to help you negotiate? Many though will likely do an hourly rate. So some lawyers will charge by the hour, even the quarter hour, and it can vary significantly anywhere from 150 an hour to 500 or more an hour. It's really going to depend on the lawyer's experience and the local market rates.

Many though will offer package deals, so some law firms can offer deals that include a contract review, some negotiation and follow up consultations for a set price. You know, to get an accurate estimate, I would contact several law offices to inquire about their rates and services. It'll also give you an opportunity to assess their experience with physician contracts and their approach to clients in general.

The standard contract review on Resolve was around a thousand dollars, but there were some lower basic reviews and then some higher reviews.

Amber N. Hardeman, MD, MPH, MBA (Host): Okay, so now that we have our contract and we have our lawyer and we know that we should be trying to negotiate things, let's talk start dates. For the first time ever, we may not have to start on July 1st, so should we take a break?

Kylie N. Jungles, MD (Host): Yeah. Melinda, do you generally recommend taking time off after fellowship or should we just jump straight in?

Melinda M. Rathkopf, MD, MBA: I recommend taking time off whenever you can. As I said, you're going to work most of the rest of your life until you fully retire, but really this is another one that depends on your priorities. Do you love to travel and would that be a good time off? Do you want to take some time or would you rather spend some time off getting yourself moved and setting up your new home? Is it just you that you're moving or do you have a spouse? Do you have kids? Do you have pets? You know, are you on someone else's timeline also, like kids starting school, a spouse starting a job in the area, and then financially, can you afford to take the time off?

You really just need to look at that and what your priorities are. Is your future employer flexible on your start date? You know, maybe they have someone leaving and they need you at a certain time, but definitely strongly consider it, and if you can swing it and your employer agrees, I recommend taking the time. You've been through this marathon of college, medical school, residency and fellowship.

And even if you didn't go straight through that gauntlet, you still have worked hard for many years. And now you're about to start that thing you wanted to do when you grow up, remember? So start it feeling ready and refreshed if you can.

Amber N. Hardeman, MD, MPH, MBA (Host): That makes complete sense. However, sometimes practices might pressure fellows to start quickly. Any advice on how to maybe navigate that conversation if we really want some time off?

Melinda M. Rathkopf, MD, MBA: Yeah. You know, I would just make it part of your negotiation. Be open and honest. Say what you've been through and when you graduate, the earliest you could leave town and let it be part of your negotiation. If it's really a good fit and they want you, they'll wait another month or so.

Kylie N. Jungles, MD (Host): That makes perfect sense. And then when we're picking the date specifically, what are some important things to consider when selecting our official start date that's going to go on our contract?

Melinda M. Rathkopf, MD, MBA: As noted above, location will play a big role. If your job is in a new state, do you need to get a medical license? In some states, this could be six to 12 months. Many states are now part of the inner state licensure compact, and it can be much quicker. But some states still take quite a long time.

You have to get moved. How far are you moving? Are you moving a family? What is your significant other's schedule like if you are moving someone with you. You have to get insurance approved, you have to get medical malpractice. So there are a lot of moving pieces that need to be in place before you can actually start seeing patients.

Amber N. Hardeman, MD, MPH, MBA (Host): Yeah. I think it's really important that we understand to factor in the time that it takes for licensing. Now, Melinda, before we close, is there anything else that you wish you would've known before starting your first job out of fellowship?

Melinda M. Rathkopf, MD, MBA: I think just knowing that everything is negotiable. I say that and then I think back to my first job, which was in the military, so maybe a little less flexible than a private practice would be, but everything is negotiable and you are your best advocate, so make sure you're standing up for what you want.

You can do that in a very polite, courteous, respectful manner. But again, you're your best advocate and you're the only one advocating for you. So don't be afraid to ask for what you want, because you just might get it.

Kylie N. Jungles, MD (Host): This has been incredibly helpful as someone that's currently looking at this transition process and it's feeling a little scary. Are there any podcast books or additional resources you would recommend for us as we start to make this transition from Fellowship into Attending hood?

Melinda M. Rathkopf, MD, MBA: I may sound like a broken record here, but again, start with the College website. So the toolkit is the FIT and new allergist toolkit. It's on the College website under the practice management section, there's an RVU toolkit, and there's many other practice management and clinical toolkits. These will link you to additional resources through MGMA, AMA, New England Journal of Medicine. All of those.

Amber N. Hardeman, MD, MPH, MBA (Host): Great. Melinda, just like Kylie said, this has been such a great conversation. I feel like no matter what stage we're at, like me in interviewing or Kylie kind of getting ready to transition into her job, or even the other fellows who haven't yet started their search, thank you so much for joining us.

Kylie N. Jungles, MD (Host): And thank you for everyone listening today. We really hope this episode helps clarify what happens after you receive the job offer and will help enlighten you as you start this process on your own.

Be sure to check out the College FIT resources and keep an eye out for future episodes in our FIT series here with Allergy Talk.

Amber N. Hardeman, MD, MPH, MBA (Host): As always, thank you for listening. Don't forget to subscribe and share with your co-fellows, and again, if you're interested in joining the FIT Committee, look out for the application to join as either a national or regional representative. If you have other questions, you can also reach out to Anna Nagel at Anna Nagel at ACAAI.org.