GET A JOB!

Learning Objectives

1. Recognize the large range of jobs available
   1. Figure out what type of job you want
2. Evaluate jobs based on your own needs and available resources
   1. Clinical hours
   2. Academic expectations and available resources
   3. Family needs
3. Negotiate the best position available
   1. Salary & Benefits
   2. Academic support
   3. Clinical Time

“There is no perfect job ”  - Nate Kuppermann

I.  What kind of a job do you want?

• This is most important and may require a lot of soul searching.
• Academic vs. clinical, most jobs will have administrative duties.

1. Definitions vary considerably – what is “protected time”
2. Pediatric Emergency Medicine (PEM) offers a wide range of "academic" jobs.

While you are considering jobs identify your needs and limitations

1.   Location - family/geography play big roles in job selection.  They also make excellent excuses - blame it on your spouse/SO!

2.   Salary - a wide range is available: in general, more clinical hours = higher reimbursement

3.   Development of the program - a key issue.

II.  Development of Program

Jobs across the country vary widely based on where they are in the development of their ED.  More established programs offer few surprises and added responsibilities.   Other programs vary from just starting to somewhere in between.  There are more turf battles yet to be fought.  Identity within the hospital, role in trauma, level of interaction with residents, and fellowship program all need to be solidified.  The disadvantage is that you are at risk of spend time fighting these battles (more administrative duties) without developing “academic products” that will lead to promotion.  Try to turn every QI project or duty into a publishable academic product.  The advantage is that newer places have more options for you to have input and find your “niche”.  Risk is inherent in any position.  Newer places are more likely to have growing pains although established EDs have their own issues as well.

III.  Children’s Hospital vs. PEM in a non-Children’s Hospital (Hospital-within-a-hospital)

Most of us trained in free-standing Children’s Hospital EDs and take for granted the benefits of working  in an environment where everybody cares for children all day, every day.  Jobs in non-Children’s Hospitals may be VERY different depending on how children are seen in the ED, staff available and your interaction with general EM docs.  Question the people that work there very carefully about autonomy, nursing skills, and job satisfaction.  You may be a part of Emergency Medicine rather than Pediatrics which has positives and negatives.  Do your homework and make an informed decision.

IV.  Calendar

Summer of Year III of Fellowship:

• Identify places that are hiring:  jobs listed in journals (PEC, Pediatrics), on-line, word of mouth.
• Send out introductory letters or emails, buff CV,  ask for letters of recommendation

1. OK to send inquiry letters/emails to places you might want to work but who have not listed open positions.  Many places may not know if they have funding for another position or not – good to let them know you are interested AND an outstanding candidate

Fall to Winter of Year III:  First Interviews

• Typically one should try to look at around 5 to as many as 10 programs if possible.

“Cast a wide net ” - Gary Fleisher

Winter, Year III:  Second Interview(s)

• Be highly selective, only interview again if you are very serious, generally 2 or 3 second interviews

Winter to Spring:  Get a Job! (You may get a job sooner but do not be discouraged if it takes longer)

V.  First Interview

Information to be obtained

The first interview is a basic fact finding mission.  However, specific details about salary and benefits may not be discussed until later.  Information will be obtained throughout your day of interviews and specific questions for specific individuals are listed separately.

Jobs are made of 4 or more components: clinical, education, research, administrator, child advocate.  Almost NO ONE can be successful at all 4.  Pick 2 on which to concentrate and be really good.  Remember your interests will change as you mature (or just get old).  Most importantly: consider your family and personal life at the top of your priority list

1.  Clinical

• Hours per week of clinical work in ED.  24-28 clinical hours per week is pretty much accepted around the country (actual range is 20-32⁺).  If you want to be a major researcher you will have to find a way to fund much less clinical time.
  • Ask about additional “hidden” clinical duties required (attend on the floor or ICU, follow abuse team patients in-house, sedation unit etc.)  These could be good or bad depending on your interests

2.  Research

• Research may be what academic programs are interested in most; be prepared to discuss your projects and interests (know about the research interests of those with whom you will be interviewing)
• What is “protected time”?  PT = 24 hours in a day - (clinical hours + time spent with administrative duties + paperwork time + your life outside medicine).
• Expectations of the institution as well as your own: do the resources available match the expectations?
• Research conference - is there a forum to present ideas for critical review
• Research mentors – you will be much more successful with good mentors

3.  Teaching/Academic appointment

• Everyone is expected to be involved in the “clinical” education of medical students, residents and fellows in the ED
• Find out about additional educational duties exist (PALS, Simulation, Mock Codes).
• Academic appointment and what does it mean?  Most PEM docs are on the Clinical Scholar Track (or equivalent).  Very few receive tenure.  Does this matter?  Typically, if you generate your salary with clinical work, tenure does not matter much.  Ask about how successful members of the prospective division of PEM are in getting promoted.

4.  Administrative

Figure out who is doing what currently and everything left over may become your new responsibility.  Some global duties include:  Scheduling, resident/medical student overseer, fellowship director, pre-hospital care, quality assurance/improvement, PALS/APLS program director, trauma coordinator, disaster medicine, hospital committees.  Request minimal administrative duties in your first year.  Expect that to increase as you go on.

Who should you expect to meet and what to ask them?

Do your homework!  Find out who does what at Potential Children’s Hospital and ask lots of questions.  Do a literature search on each potential interviewer/new partner.

Chief, Division of Emergency Medicine

This person is KEY.  This is your new boss.  Can I work for this person?  Will this person have my best (career) interests in mind?  Do they have a national presence - will I get their scraps (chapters, projects, papers they are too busy to do)

• Expectations of junior faculty.
• Research support (stats, computer, secretarial help, start-up funds).
• “Vision” of the department’s future.
• Before you leave on the first day find out:  number of positions open, time-line for hiring, and ballpark salary figure (try not to sound too interested in the bucks).

Faculty, Division of Emergency Medicine

• What is working in the ED like, actual hours and shift schedules, nurses, fellows, residents, consults, surgeons, radiology

Fellows, Division of Emergency Medicine

• Are they being educated or are they service machines
• Projects, conferences, journal club

*Nurse manager/coordinator department of Emergency Medicine

• Collaborative care model- let them know you have a clue
• From where do they come (ex-ICU nurses, experience)
• Nursing’s expectations (IV’s, bloods, caths, partners in research?)

Chairperson, Department of Pediatrics

• View of PEM with regards to health care reform (is there a plan?)
• How to support academic endeavors (hours, cash, statistical support)

Chiefs or Faculty from divisions within Pediatrics

• Do they have a clue about PEM?
• Reputation of PEM within the hospital

Personal information

Your personal life is your own business and off limits to questioning for potential employers.  However, most questions are earnest attempts to find out what type of information you need to be sold on their city.  Offering some personal data (family needs etc.) is usually in your best interest.

Emergency Department

You can gain lots of information by wandering around the ED.  How does it function?  Watch how attendings, residents and nurses interact.  Proximity to Radiology. Lab turnaround time.

City

“The coldest winter I ever spent was a summer in San Francisco” -  Mark Twain 

Do you really want to live here?  Will your spouse live here?  Is it a good place to start or raise a family?

Preparation

“Luck is the residue of design” - Branch Rickey, baseball executive

Be prepared for difficult questions.  Find out about a place and the people ahead of time so there are no big surprises when you get there.  (Somebody from your program knows them well)  We operate in a small sub-specialty.  There are very few big secrets. The major drawbacks of any institution become evident very early.  This is because people want to paint an accurate picture of their place.  They want you to decide if you belong.  Unconsciously (or consciously) they will invariably downplay the negative and emphasize the positive.  But remember one of Roback’s rules on human nature:  Pediatricians are poor liars.  Do not be afraid to ask tough questions of people directly.  Try to phrase them in a non-threatening manner.  “Can you give me examples of things you would like to change?”

“Set yourself up for victory ” - Mark Roback

• You are in a good position.  You have a lot to offer.  Tell them about interests through questions.  “I am really interested in your research on XYZ.”  “I frequently did mock codes with our residents and really enjoy education.  Tell my what you all do for education with fellows and residents.”
• Your C.V. will get you in the door, but you have to sell yourself.  Let them know what you’ve accomplished in your fellowship (besides pushing cartloads of patients).
• Options - visit several places.
• Let ‘em know you have several options (they will certainly ask where else you have looked).
• Do not share your limitations or restrictions.

VI.  Second Interview

Only go to 2 or 3 places a second time.  This visit should be reserved for jobs you would more than likely accept if offered.  You will meet the big shots but also try to meet any faculty (potential peers) you may have missed or would like to see again.

“You go to work cuz they pay you money ” – David Roback (my brother the business man) 

More and more people will tell you up front what the salary will be.  As dumb as people like my brother think it is, we in academic medicine are reluctant to talk much about money.  If salary is not mentioned by the end of your first visit, ask the Division Director to give you a “ballpark” salary figure.  This is only reasonable.  When they offer you a job they will tell you the salary.  Some places (non-academic usually) it is a dollar/hour figure that is not negotiable.  If they give you a yearly salary figure it is reasonable to ask “is that figure negotiable?”  Say something like, “I have large educational loans, we will be taking a bath when we sell our existing home, and we have 12 children; I was wondering if the salary is at all negotiable?”  This is also reasonable and they will probably respond with, “let me get back to you on that”.  They may or may not be able to increase but if you do not ask, you will never know.

Be very careful when discussing salary.  Vigorous discussion about money/salary is NOT in your best interests and will alienate people.  Negotiate for resources that will make you more successful and enjoy your job more.  Asking for research support and protected time will be much better received than asking for more money.  Negotiating chips on your side (besides your “most excellent” fellowship training) include additional training (M.P.H., PhD, chief resident) or any other additional, sellable experience (research grants, administrative, people managing).  NOW is the best time to negotiate.

Negotiable entities include:

• Salary - may be fairly rigid but if they want you badly enough...
• Benefits? - vacation, CME time, educational fund (not negotiable at many placed)
• Research start-up funds - must display a research history and a “plan”
• Computer - display a knowledge and need
• Office space - be reasonable
• Starting date - bring this up at the very end – take the summer off if you can swing it

Timeline

“It ain’t over, ‘til it’s over ‘- Yogi Berra

"The opera ain't over till the fat lady sings." - Dan Cook (sportswriter and broadcaster)

It will not take forever to get a job but it may seem that way.  Patience is absolutely required.  Every institution has its own timeline.  Most places have moved more slowly of late due to a variety of factors such as the lousy economy and uncertainty of funding for positions.

Write down details and impressions after your first visit so when you go for your second in a month or more you will have some recollection of the specifics of the place.

No matter how weary you become do not give in.  Continue to explore other options.  Until the day you accept a job ANYTHING can happen.  Try not to let time influence your ultimate decision.  Be patient!

Remember:  “No job is forever.” - Grace Caputo

However, try not to jump from job to job.  When you take a job, think 3-5 years and then re-evaluate.  However, if you are certain the job is wrong for you, it is time to leave.  Try not burn your bridges, PEM is a very small world – we all know each other very well.  Blame it on you spouse.

GOOD LUCK!

Mark G. Roback, M.D.

Pediatric Emergency Medicine

University of Minnesota – Amplatz Children’s Hospital

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