Finding a Standout Physician to Hire

Be thorough or be sorry.

By Jerry Helzner, Senior Editor

A major ophthalmology practice in a state with a large population of retirees recently hired a standout, fellowship-trained retina specialist and guaranteed him a $300,000 salary for his first year, the largest guarantee the practice has ever offered. Though the practice did not expect this young doctor to make a contribution to profitability until his second year, he made his guarantee and then some in year one.

At another Sunbelt practice, St. Luke's Cataract & Laser Center in Tampa, Fla., a large, multi-location practice that employs 19 ophthalmologists, practice administrator Brad Houser says the practice is “generally pretty active” in the hiring marketplace. He reports that there is high demand for fellowship-trained retina and glaucoma specialists.

“We have three retina specialists in our practice and we will soon be looking for another,” says Mr. Houser. “It is now possible for retina specialists to intervene earlier in the disease process, which makes them more valuable to the practice.”

St. Luke's recently hired a Wills Eye-trained glaucoma specialist who has worked out nicely for the practice.

“Glaucoma is a difficult patient population because you are primarily trying to keep the patients from going downhill,” says Mr. Houser. “However, this doctor we brought into the practice is well-versed in the newer surgical alternatives for glaucoma treatment and he has helped us widen our range of glaucoma procedures.”

James Dawes, chief administrative officer for Center for Sight in Sarasota, Fla., is another practice executive who sees rowing demand in the retina and glaucoma subspecialties.

“Glaucoma and retina procedures are now more commonly being performed in outpatient surgery centers than ever before, which is also driving ophthalmologic surgery practices to expand in these areas,” Mr. Dawes says.

These reports from the front lines of the hiring process offer a couple of clues to the current hiring environment for specific subspecialists. First, with the aging population and its clustering in Sunbelt states, first-rate retina and glaucoma specialists coming out of fellowship training are in great demand and can ask for (and usually receive) compensation above the levels of previous years. They also can be “safe” hires because their patients almost always require lifetime care, and, in the case of retina specialists, more resources are being allocated for the treatment of diabetes and diabetes-related diseases.

It should also be noted that, even with compensation increasing for these subspecialists, in the right situation some new hires can make a quick and sizable contribution to practice profitability.

But what about the nuts and bolts of the hiring process itself? What can a practice do proactively to ensure that it hires the right subspecialist or generalist, or is making a good decision in adding a pediatric ophthalmologist to the mix? This article will explain how practices with superior hiring and retention records go about recruiting a new physician and successfully bringing him or her into the practice culture.

When to Hire

Almost all practice administrators say that the need to hire a new physician should be anticipated 12 to 18 months in advance of the actual hire, so as to leave time for the recruiting and credentialing process to proceed without undue haste. You do not want to be faced with a situation in which patient demand is so great that the ophthalmologists already in the practice are pressured and unable to schedule appointments in a timely manner. A patient who can't get an appointment in a reasonable time is likely to go elsewhere.

The time pressure is not as great when a practice is seeking to add a new subspecialty to its range of services, but you will still have to deal with months of planning, recruiting and credentialing before the new subspecialist can contribute anything to the practice.

If increased patient demand has taken the practice by surprise and you need to act more quickly, consider hiring a residency-trained OD with comanagement experience and let the OD take some of the primary care load. Have the ophthalmologists just focus on surgery.

Money Well Spent

Talk to practice administrators or partners who have been successful at recruiting new physicians and they will readily concede that recruiting is an expensive and time-consuming process. However, they will quickly add that failure to properly and thoroughly evaluate candidates will lead to bad hires that can set a practice back years.

Amir Arbisser, MD, founder of Eye Surgeons Associates, with five offices in Iowa and Illinois, says that his practice has always adhered to the principle that bringing on a new doctor is a key decision that can have implications for decades. Therefore, the practice is willing to make a significant investment upfront to ensure the most thorough screening process — including visits to the candidate's current workplace — leading to the best possible choice.

“We want to see the doc in their presumably comfortable current training location,” asserts Dr. Arbisser. “How do they interact with patients in the clinic? How do they interact with staff? Do the OR nurses and techs seek to greet the doc, a reflection of previous friendly behavior, or do they avert their gaze to avoid interacting with our candidate?”

Dr. Arbisser says the site visit provides an opportunity to watch a candidate treat patients and to observe how the doctor conducts himself or herself.

“We know newbies don't perform technically at the level of mature surgeons, but how does the doc handle tissue?” Dr. Arbisser asks. “If there's an adverse occurrence, how does the doc deal with the stress?”

Dr. Arbisser notes that surgical behavior cannot always be observed personally so appropriate subspecialist surgeons also preview the applicants' videotaped cases as an alternative.

“Yes, it's expensive for a partner to go on the road for a day or two to assess a finalist candidate, but it's much cheap er than signing the wrong doctor, credentialing them and moving their family to town, introducing them to patients and referral sources, and then legally extricating the parties months or years later, Dr. Arbisser concludes. “A site visit is an incredibly positive demonstration of how serious the hiring practice is about a candidate. This really counts when trying to interest a doctor in a backwater location. You are going to spend more time with this person than with your spouse. We are willing to make the investment to make sure that we make the right choice.”

Hiring Priorities

Asked to enumerate the priorities that go into a hiring decision at St. Luke's, Mr. Houser says most important is that the candidate should be a good fit with the practice culture and have career goals that are in accord with what the practice can offer. “Personal chemistry is a major element of our hiring process,” says Mr. Houser.

At St. Luke's, a candidate's career goals can sometimes be a sticking point.

“St. Luke's is owned by the Gills family, so there is no partnership track available here,” says Mr. Houser. “We have lost some entrepreneurial candidates for that reason but we have gained others who want to practice their profession without the burden of making an investment.”

The practice location may also be an important factor for the candidate, especially if the potential new hire has a young family and a spouse with a career, which is generally the case.

“If there is a good opportunity for the spouse to obtain meaningful employment in your area, you have a much better chance of winning over the doctor,” says Mr. Houser.

Adds Dr. Arbisser: “Dark exam rooms and surgical theaters are essentially interchangeable in Davenport, Iowa, or Denver, Colorado, but spouses ultimately interact full-time with the community at schools, at cultural and religious institutions and at various events. They are an important key to the success of the recruitment effort.”

Dr. Arbissser advises practices in hiring mode “to recruit the spouse to the community and to arrange appropriate opportunities and interviews.” He says selected realtors also collect helpful data. They can spend hours with the candidates and spouses and often hear their candid remarks and concerns, which frequently prove helpful to practice decision-makers.

Compensation Not the Key Priority

Interestingly, though compensation is always an issue once the initial hiring hurdles have been cleared, St. Luke's has rarely lost an ophthalmologist it wanted to hire over money.

“When we get to the stage of making an offer to a doctor, we can almost always work something out that's fair to everyone,” he says.

Many agree that the new physician should be given guaranteed compensation for at least the first year.

“We provide a guarantee and fairly low patient volume for the first year,” says Dr. Arbisser. “We want the new doctor to spend time enhancing the patient experience with no distractions. With patient care as the sole focus, the doctor begins to earn a positive reputation in the community.”

Mr. Dawes says that Center for Sight provides a guarantee for the first year only. “After that, the guarantee is eliminated,” he says. “We are looking for entrepreneurial physicians. Our compensation structure encourages the surgeon to work hard to build the practice, just as any new business owner would have to do; a prolonged guarantee creates a false sense of security for the new physician.”

Another practice administrator advocates a transparent process for setting compensation. He advises that any practice, large or small, is best served by having no secrets.

“We will show the new hire our numbers,” he says. “We find that the best approach is to be fair and equitable in determining compensation. Don't look at the new doctor as a cash cow for the practice.”

Finding Good Candidates

St. Luke's generally uses headhunter firms to send the practice candidates for open positions. In some specific instances, such as the hiring of a specialist in oculoplastics, the headhunter firm will be given the exclusive right to find appropriate candidates. For other hires, where a wider net can be cast, several headhunter firms are invited to recommend candidates on a non-exclusive basis.

“Using headhunter firms has worked for us,” Mr. Houser asserts. “We may wind up bringing in three to five candidates for a visit for each position, but we'll probably do a telephone interview with three candidates for every one who we eventually bring in for a visit.”

Mr. Houser says the most difficult (but most important) part of evaluating candidates is to predict how they will fit into the practice culture.

“Let's face it,” he says. “They are all smart and they all interview well. Our task is to look deeper and determine if that good personal chemistry is there. It's so key that they have that because we are asking new doctors to get out in the community, build their own practice and generate referrals. The west coast of Florida is a highly competitive area for ophthalmology practices. We have a leading position and we want to keep it.”

Is Experience a Plus?

A practice administrator may find that an ophthalmologist with the right skill set who has been in practice for several years may be the best choice.

“These doctors tend to have realistic view of what it's like to be part of a practice in the real world,” Mr. Dawes asserts.

Mr. Dawes also notes that a new hire who has established a good reputation locally and who has ties to key referrers can be a safe and highly productive choice.

“Selecting someone who is already in the local market and is known — maybe a doctor who has been in competitive practice — has worked well for us,” says Mr. Dawes. “It is critical that the new doctor is able to establish good relationships with our referring physicians.”

Another administrator notes that there are advantages and disadvantages to hiring someone with experience, just as there are advantages and disadvantages to bringing in an ophthalmologist directly from fellowship. For example, a seasoned physician has more of a work history that can be evaluated but may have developed bad habits in a previous workplace. A doctor coming straight from fellowship is more of an unknown but can be more easily trained in the methods and techniques favored by the practice.

“In addition to the broad traditional recruiting net, we also seek potential candidates through other professional activities,” notes Dr. Arbisser. “Dr. Lisa Arbisser frequently speaks at major meetings and educational institutions on topics of anterior segment surgery and vitrectomy for anterior segment surgeons. Those meetings provide face-to-face opportunities to develop future prospects — even when we're not actively recruiting.”

Dr. Arbisser says his practice is usually a bit overstaffed as a safeguard against suddenly losing a key person through illness or for other reasons. “It's better to have a little bit of depth on your staff,” he asserts.

Smaller practices seeking to expand might consider adding a pediatric ophthalmologist, says Dr. Arbisser. “Once you have the children coming to your practice, the mom, dad and grandmom are likely to follow,” he says. “So adding a pediatric subspecialist can be helpful to the entire practice.”

No Sure Way to Hire

There's no sure formula to successfully bring a new physician into a practice, says Mark Rosenberg, executive director of Barnet Dulaney Perkins Eye Center, a large Arizona practice, noting that hiring physicians is more of an art than a science.

“You can have very narrow ideas about the type of person you want to hire, but that just might cause you to miss out on a superior candidate who can make a great contribution to your practice,” he says. “Once we understand the candidate's objectives, we can discuss the attributes of our practice that the candidate will find most appealing,” he says. “The best candidates are going to have multiple offers. By understanding what the candidate is looking for, we can show that our practice is the best choice for that doctor to achieve his or her career goals.”

Mr. Rosenberg says that every successful hiring decision is an exercise in meeting the expectations of all parties.

“There is always a tradeoff,” he says. “It's measuring what the doctor wants for himself or herself against what's good for the overall goals of the practice. If you can manage these expectations, you have probably made a good hire that will benefit everyone in the long run.” OM

Two Different Paths, Two Different Goals

Priscilla Fowler, MD, who is currently completing a one-year fellowship in cornea at Wills Eye Hospital, is preparing to enter the job market for the second time in six years. Her first job search, following her residency at the University of Alabama Birmingham, was rather uneventful. However, this time she will be armed with the advanced credentials from a prestigious eyecare center that she believes are necessary for her to reach her longer-term career goals. “When I was finishing my residency at UAB, a friend told me about an opening for a general ophthalmologist at a private practice in Destin, Florida and that was pretty much it for my first job search,” says Dr. Fowler. The Destin practice was in a high-income area on Florida's Gulf Coast and the practice included a high-percentage of wealthy retirees. “I did a lot of cataract surgery and some aesthetics,” says Dr. Fowler. “After a few years, I decided I wanted to specialize in cornea and I applied for the fellowship at Wills.” With her advanced training, Dr. Fowler's goal is to combine private practice with an academic position. “I would like to do both,” she asserts. “Academia is appealing because you really do get to work with a lot of bright people in those institutions. Also, being in private practice in a small town can be a bit isolating.” Dr. Fowler has family ties in the southeast and her husband's job requires that the family (which includes a three-year-old daughter) be located near a major metropolitan area. “We are looking at the east coast, with Atlanta or Miami being ideal,” she says. “I do have interest in corneal transplantation and would like to be involved purely in cornea if that is possible.” Dr. Fowler is a bit dismayed to find that the AAO Web site for job opportunities is heavily skewed toward retina and glaucoma openings. However, being fellowship-trained at Wills will probably catch the attention of so-called “headhunters” who find good candidates for practices seeking to fill slots for new physicians. “I am being recruited but so far it has been by people and practices that already know me,” says Dr. Fowler. “I would not say I have been aggressively recruited as yet.” Dr. Fowler says she has discussed the job search process with one co-fellow and that he is limiting his choices because of a desire to work near where his fiancée lives. “It gets a bit more difficult when you limit yourself,” she concludes. “I would be willing to consider almost any metropolitan location on the east coast.” Dr. Fowler. Amanda Matthews, MD, a third-year resident and chief resident at Wills Eye, is headed for private practice in comprehensive ophthalmology in her home state of Georgia, close to family and friends. She weighed all of her options and decided that this was the best path for her to pursue. “I was recruited by a private practice in South Alabama that is opening up a new branch office in South Georgia,” she says. “I believe that my training at Wills certainly made me attractive to the practice owner since he is a Wills alumnus.” Dr. Matthews says there are many reasons that she chose comprehensive ophthalmology, including the ability to immediately start practice after residency, as she was not interested in going into fellowship. “I feel like I can offer a variety of services to patients without boxing myself into one specialty,” she asserts. “I am from Georgia and wanted to go back. I am more comfortable having a family in a suburban setting and we will be close to family. The practice is very stable and I have the opportunity for partnership after two years.” Dr. Matthews feels that the overall job market for ophthalmologists about to enter practice is “a great one,” with the aging population exploding and a need for ophthalmologists in more rural settings. “I think that glaucoma seems to be a subspecialty that is highly marketable right now,” she notes. “Everyone seems to be looking for a fellowship-trained glaucoma specialist.” Dr. Matthews believes that personality plays a large part in finding the right fit for a practice. “That is why it is so important to go interview and spend time with the people that you will be working beside everyday,” she says. “The great thing about coming from Wills is that you are more than prepared to enter a busy comprehensive practice and manage anything.”

Out of Training — And Into the Job Market

Just about a year ago at this time, Daniel F. Kiernan, MD, was completing his retina fellowship at the University of Illinois-Chicago and preparing to enter the job market. The son of an ophthalmologist, Dr. Kiernan knew that his first-rate training, his choice of specialty and his extensive experience in research would all make him a highly desirable hire in the current ophthalmic marketplace. However, he did not take his job search lightly. Instead, he used all of the tools at his disposal to land a position at a highly respected practice, The Ophthalmic Consultants of Long Island, whose goals for a new retina specialist meshed with Dr. Kiernan's career goals. Following is a Q&A with Dr. Kiernan as he relates the details of his job search and offers tips to other young ophthalmologists seeking to find the position that best meets their goals. Q. As a young retina specialist, were you heavily recruited or did you actively market your skills to practices/institutions where you wanted to be employed? A. As far as job searching, It's a two-way street. Retina is definitely ‘in’ right now, with a large population to serve that's getting bigger with each year. it's an expanding niche that many practices are looking to fill. Of course, finding the perfect job is still a challenge. I actively placed my CV on many different recruitment lists, as well as the AAO and ASRS job lists. My mentors went out of their way to mention my name at retina conferences. I set up job interviews at all the meetings I went to and I told all the pharma reps that I worked with to put out their feelers for me. All these methods had productive results in terms of generating opportunities to explore both academic and non-academic job offers. In the end, the job I took was a result of word-of-mouth from my mentor, Dr. Bill Mieler, speaking with another member of the Retina Society, Dr. Glenn Stoller, after I gave a talk at the 2010 Retina Society Meeting in San Francisco about en face spectral domain OCT and its relationship with visual acuity. Dr. Mieler then shot me an e-mail to say that Ophthalmic Consultants of Long Island was looking for another retina person. Q. What are your career goals and what type of position were you seeking? A. Coming from a heavy academic background with lots of research under my belt, I was initially interested in an academic position. However, that is a tough market in which to find an ideal job, especially in this economy. The jobs that were available to me didn't fit with my ideal academic dream, so I kept an open mind and continued interviewing in the private sector, with much better results. My goal was to find the best possible job in terms of practice reputation, patient volume and people to work with on an every day basis. I was very open to changes in terms of geographic location, which helped exponentially increase the offers I received. Dr. Kiernan, now a practicing retina specialist on Long Island, performs argon laser photocoagulation using a Pascal laser. Q. Did location of the practice play any role at all? A. Location was less of an issue than other factors. My wife was born on the West Coast and grew up in Idaho and I'm from Chicago, so after a frank discussion with her, we agreed that there weren't too many places that we wouldn't go, although being close to an urban area would be more ideal. Nevertheless, several places that we visited during the interview trail were very rural, but were still quite high up on our list. Q. Did you have family considerations in your job selection, such as a working spouse who needed to also have access to a good job? A My wife Kristi, who is a psychiatric nurse, received a job offer to be promoted to head nurse supervisor in the largest psychiatric hospital in Chicago, less than a year after starting working there. This was around the time we were deciding what to do for my job. It was a very heavy decision for us to have her give that up to move to New York. Also, I am the oldest of 12 and my father is an ophthalmologist in the Chicago suburbs. The option to work part-time with my father was on the table as well, but the retina market in Chicago was not ideal, and I didn't want to be the only retinologist working full time for another practice and part time with my father. Although my training was certainly sufficient for me to “handle anything,” I really wasn't comfortable having no other retina partners to work with. None of the retina groups in the Chicago area were hiring during my job search, plus that market is already over-saturated and the groups there were very limited in terms of growth potential. Q. Did the offers (or interest in employing you) meet your expectations? A. All the offers were roughly equivalent in terms of starting salary and incentive bonus but there was a huge discrepancy in terms of perks (or lack thereof) in the offers I received. My current employer pays all of my medical and dental insurance for my wife and I, and that was not offered with any of the other practices where I interviewed. I have a 401k plan and an annual professional allowance to pay for society memberships, journals and meetings. Contract negotiation was also paramount to my final decision. A number of individually owned practices basically would not negotiate anything with me about their offer, whereas the practice I joined is a large one and I was able to negotiate to some extent. They generously increased several details including raising the moving allowance (it always costs more than you think to move!). Overall, it seemed like the market had a lot of jobs to offer but I got lucky finding a single good one. I feel that most of the other offers would not have been personally satisfying for me. Q. Did compensation and future opportunities at the practice meet your expectations? A. That's hard to say. My offer was certainly fair by market and geographic standards. There were some rural offers that were pretty generous — $1 million per year in Guam, $750,000 in Saudi Arabia, $600,000 per year in North Dakota, but those places weren't really the most suitable for me or my family. The future opportunities at my practice, and the promise that I would be busy, with a healthy patient volume were compelling. Plus, seeing proof that the other retina partners WERE actually busy when I visited the practice locations during my interview left me with an extremely positive “gut feeling” initially that only improved as time and the negotiation process went on. Q. Has your current position and the realities of everyday practice met your expectations? Any surprises or challenges that had to be overcome? A. It is the “practice” of ophthalmology and like any other art, it's not a cookie-cutter position. I have challenges and mental and emotional thrills everyday. The surgery is and always will be challenging and different than any other aspect of medicine. Vitreoretinal surgery is not something that anyone can just “do.” Everything about my current position has met and exceeded my expectations. I'm very busy, though managing to avoid feeling overwhelmed. My surgery volume is healthy and the people I work with have been great. Since mid-July I've had about 1,300 patient visits and done 28 OR surgeries. Q. How would you evaluate the overall job market for ophthalmologists about to enter practice? A. I can only speak for retina, as I have just done. My experience for other specialties is limited to my co-fellows experience while I was in Chicago, and it seems similar to mine. The market is open but the perfect job will always be tough to find depending on your personal preferences. Maximize your opportunities by using a “shotgun” approach and be sure to use your mentors' word of mouth. I felt a little turned off by some of the “mass-recruiter” companies, and they really don't seem to care if the fit is right or not. It's important to take the time to go and see the practice, especially the area around it and bring your spouse or loved one. Happiness is a complex myriad of details and the “perfect job” is the one that makes you happy.

A Primer for Making the Right Choice What factors the job seeker should consider. By Nicholas H. Tosi, MD The prospects of entering the marketplace after ophthalmology residency, while exciting, are not as straightforward as observers often assume. Since ophthalmology is one of the more competitive subspecialties and accepts only about 500 new residents annually, figuring out where to practice theoretically should be easy. However, in talking to several of my colleagues, it becomes apparent that a multitude of factors influence decision-making leading to competitive placement into a desirable practice environment. Location, Location, Location It is clear that there is a large income difference solely based on the size of the city. As Haroon Chaudhry, MD, a vitreoretinal fellow currently applying for jobs throughout the country, attests, “The larger metropolitan areas offer 50% to 75% of the salary of smaller cities and towns and also are more competitive markets to build a referral base.” Mahdi Basha, MD, a glaucoma-trained comprehensive ophthalmologist at OptiVue in northwest Ohio, similarly concurs after his job search one year ago. “If you can do rural living, these practices can be a starting ophthalmologist's dream. I know rural ophthalmologists who are two to three years out making more money than several urban ophthalmologists while living a calmer lifestyle, with fewer headaches.” Additionally, longer partner tracks and larger buy-ins are more common in the more saturated urban markets. In my own observations examining openings, young ophthalmologists searching for a first job will undoubtedly face a large economic trade-off to live in bigger, more popular cities. It also generally follows that a similar opportunity cost exists for practicing at an academic institution versus private. What's My Market Value? Another problem for new practitioners is the absence of knowing their true market value. Salary surveys are lacking and there is a near universal absence of starting salaries as part of job postings themselves. This misinformation then becomes integrated into the interview itself, putting the applicant at an inherent negotiating disadvantage. Dr. Basha points out an extreme case. “I arrived at an interview where the employer offered me a starting salary of $125,000. When I was asked what I thought of the offer, I stayed quiet. The offer was then raised to $180,000. I remained quiet again. The third offer was $250,000. Needless to say, I never took that job.” Based on this example, one would be doing a disservice to oneself without figuring out similar regional salaries, both through networking and having more interviews. Since finding the perfect job is difficult, a large percentage of ophthalmologists generally leave their initial practice within a couple of years. Dr. Basha recommends starting a job search 12 to 18 months in advance to critically analyze the factors that could make or break long-term success. Indeed, several of my colleagues in residency who plan to go into private practice have already started this process within this time frame and are already negotiating with potential employers as second-year residents. I have also witnessed other cases where the job search began much later, and not coincidentally, fewer options were available. The late starts led to a stressful scramble for a first job. It is therefore a wrong mindset to believe that job opportunities will be plentiful and simply present themselves. The same amount of intensity and energy applied during residency should be applied to the first job hunt, as residency is only the first career step. Ask the Right Questions Other considerations ought to factor into decision-making by asking the hard questions during interviews. Who have they hired in this position last? Why did they leave? What are their overhead costs? How many employees do they have? How many administrators? Who is bought into the practice and why? When can you buy in? It also may help to call former employees to get the scoop on why they left. Dr. Chaudhry observes that the typical practice hiring scenarios he has seen include: ► There are too many patients for the current physicians to see. ► The practice is replacing and buying out a senior partner who is retiring. ► The practice is adding a new specialty to a group. ► The practice wants more physicians to share overhead and call coverage. ► The practice is expanding to a new office/area. ► The practice wants to generate more revenue. Understanding these practice dynamics and matching the practice's priorities with one's career goals is another key consideration during a new ophthalmologist's first job search.

Nicholas H. Tosi, MD, is currently completing his residency in ophthalmology at LSUO-schner in New Orleans.