Finding Your First MFM Job After Fellowship

An MFM Fellow-in-Training Employment Search Guide

By Dan O’Keeffe, MD, and Brian Iriye, MD
Society for Maternal-Fetal Medicine
Association for Maternal-Fetal Medicine Management

Introduction

The following is a compilation of recommendations to assist fellows as you consider opportunities for your first job as an MFM sub-specialist. The guide is not all-encompassing but is meant to give you background knowledge based on other’s experience that may help you make preliminary decisions as to what type of practice you want to pursue, prepare for the interview process, gain insight into some employment contractual language, and prepare for anticipated future changes that may impact your career. Most of the recommendations apply to either university or non-university jobs. However, where a recommendation applies to one or the other, it is expressly noted.

SECTION I: Insights from your peers: What I wished I had learned or done during my fellowship

I wish I had learned that I should make as many “independent” decisions as I could and then get input into why others agree or disagree. It would have helped when I became responsible for making the final decisions when I went out in practice.

I wish I had thought about what skills I needed to have in my toolbox when I went into practice, and focused on learning them during my fellowship – some of these include fetal echo, CVS, 3-D ultrasound, cesarean hysterectomy, critical care, etc. Toolbox skills required for university practice but still important in community based employment includes skills in presentation, writing, generating ideas, study design, and statistics.

I wish I had scanned more, operated more and read more.

I wish I had taken every opportunity to select more than one mentor and wish I had spoken frankly to my mentors from various walks of MFM life (private practice, academics and research) early on about the pros and cons of a career choice.

I wish I did not spend so much time worrying about the politics of my institution and spent more time learning.

I wish I had done more to build my business skills and coding skills, like taking the Society for Maternal-Fetal Medicine (SMFM) coding course or joining the Association of Maternal-Fetal Medicine Managers (AMFMM), regardless of whether I was going into Community or University Practice.

I wish I developed a niche in MFM, with first-authored publications of original research in that field.

Most first jobs are not (usually) where you will stay forever. Consider taking the first job with the idea that it is a ~5-year commitment. This is important for career development and so that your new employer (which is investing in your success) gets solid time and effort from you.

Don't be concerned if the research project you did as a fellow is not directly applicable at your new place: fellowship research studies may become the basis of your career- but likely will not. The skills you learned while doing the project are more important than the actual project. The issue is: do you like to conduct research and want to continue contributing in this regard? If the job is good but the things that interested you during fellowship aren't available, will that work for you?

SECTION II: What to look for in a job

A. You should look for universal things whether you pursue a university position or work as a hospital employee or in private practice. We will cover these universal points first and then specifically talk about the other areas.

It would help if you had a clear understanding of what the practice looks like. It would help if you understood what their mission is.
You should understand their strategic plan, see their goals (Short-term, intermediate-term, long-term), and be aware of any anticipated changes in leadership.
It would help to ask how often the doctors, nurse practitioners, and nurses get together to discuss patient care and business issues.
Meet with non-leadership people and staff one-on-one
It would help if you talked to the support staff to see how they are treated
Ask about people who have left the practice in the last three years and ask why they left. Consider giving them a call so you can get both sides of the story
You should speak with the professional practice manager and discuss the practice’s financial status and budget. Your future employer should also have a marketing/growth plan that they can share with you.
It would help if you understood the expectations for clinical performance and volume (e.g., what is the anticipated time commitment, what RVUs are expected, will travel to more than one location be required, and how will your clinical performance be monitored). Ensure you understand what electronic medical record is used in practice and any associated hospital, including if these communicate with each other and what support structure is available.
Regardless of where you practice, you should understand if there will be opportunities or expectations for teaching and administration and opportunities for advancement in these areas.
Similarly, you should be aware of ongoing or planned research that you could participate in or will be expected to support and of opportunities to develop your research if you want to pursue this.
Ask if there is a structured mentoring program and who would be the mentor. This will be important for you regardless of whether you pursue an academic or non-academic career.
You should understand your prospective employer’s requirements for specialty and subspecialty certification, maintenance of certification, and ongoing CME and determine if the employer will cover some or all of the cost.
You will find that there will be different employment models in various practice types. You need to understand the model in place (e.g., employer-employee, partnership or employee with potential for collaboration, practice/institutional/University employment, or a combination of these.
Similarly, practices vary in terms of night calls, in-house calls, and group coverage, and you should understand what will be expected of you and what you can expect from your partners.
Importantly, you need to understand how your performance will be evaluated, who is responsible for this, and how you will receive feedback, including how often this will occur.
Ensure you understand what EMR (Electronic Medical Record) is used in the office and hospital.

B. Before you start looking for a job, you need to sit down and determine what you want. Where do you want to live; more importantly, where does your spouse want to live - if your spouse is unhappy, you will not be satisfied. You need to understand what type of practice you wish to join.

Ask yourself the following questions about what you are looking for.
For each answer, ask yourself why if you start with why, the how, and what will fall into place. The answers will not be mutually exclusive!

Is it clinical or academic?
Is it teaching or non-teaching?
Is it research or not?
Is it private, hospital-based, or university?
Is it consultative, ultrasound, or deliveries?
Is it one location versus many locations?
Is it a partnership or an employer-employee relationship?
Is it full-time or part-time?
Is patient care shared or individual?

C. If you are considering a university academic practice, you also need to ask the following questions:

Is there a structured mentorship program within the department?
What opportunities are there to help junior faculty develop?
What role are the Division and Department looking to fill?
What are the research opportunities, and will I have protected time?
Will I have any research or administrative assistants?
What are the ranges of percent time spent by different members of the MFM section in clinical, research, administrative, and educational endeavors? What is your expectation now, and when, if ever, is it expected to change?
What support (money or infrastructure, including research nurses and equipment; research cores, such as in statistics) is available to assist with the research and academic pursuits?
How are expectations established for academic and educational productivity (e.g., publications, grants, education programs)?
Are educational and academic pursuits financially incentivized in any way, and if so, how?
Are there institutional funding opportunities for young investigators?
What are the different promotional tracks (including tenure versus non-tenure), the expectations for each, and which track would you most likely join?
What is the research mentorship structure for the Department and the MFM Section?
Is there a history of successful mentorship in the Department and MFM Division? If so, in what forum (e.g., helping establish independent investigators, helping faculty members become involved in local or national institutions, etc.)?
What is the regional and national reputation of the Division, and how well-recognized and connected are the faculty?
What type of research is being conducted at the institution (e.g., clinical trials, basic science, database, epidemiology, health policy), and how would I fit in?
Is there a MFM fellowship program, and how is it doing?
Who runs the obstetrical service? Are the MFMs just consultants?

D. The people you work with will make or break your job satisfaction. They are much more important than area or location. This cannot be stressed enough. You can work in the best location in the world, but if you are unhappy at work, where you live will not matter. You must look at your future employment as an area where mutual respect, communication, and lifetime goals are respected. In turn, you have to join a practice where the culture shares goals, ethics, and work styles that are similar to yours so everyone is in sync and working in the same direction.

It would help if you understood their practice philosophy and the values (core set of standards) they live by. Values include respect, accountability, excellence /scholarships, fairness, and transparency. It would help if you also asked them what their norms are (how people are expected to interact and behave within a group, not only with their peers but with the people above them and below them).

The traits that you should be looking for are:
1. They talk straight
2. They demonstrate respect
3. They clarify expectations
4. They listen first
5. They keep their commitments
6. They practice accountability
7. They deliver results
8. They are nice
9. They have high emotional intelligence

a. Self awareness
b. Self regulation
c. Motivation
d. Empathy
e. Social Skills

10. In a university, do they have a successful track record of actually mentoring young people

Some examples of the norms for interaction you should be looking for are:
1. All issues are on the table to be discussed
2. Honesty without repercussions (that is, nobody should have any worries about repercussions when speaking honestly)
3. Deliver the complaint to the correct person and do it respectfully
4. Accept your mail as just information - not a personal attack
5. No personal attacks on a person’s values and no defensiveness
6. Impeccable communication
7. Impeccable listening
8. Expectations are clear and applied consistently

SECTION III: What practices are looking for in a candidate for their position

Most people see Maternal-Fetal Medicine physicians as leaders. The behaviors that they look for can build trust. These are traits they will be looking for when you interview for their job.

They want someone who will:
1. Talk straight
2. Demonstrate respect
3. Clarify expectations
4. Listen first
5. Keep commitments
6. Practice accountability
7. Deliver results
8. Give added value to the practice or academic mission, not just a body to do more work.
9. Be nice - employers know they cannot teach nice
10. Work well with staff, peers, and referring physicians
11. Has a philosophy of practice and life that fits the philosophy of the group
12. Be a team player both with staff and peers
13. Is honest in what they are looking for in their job
14. Has high emotional intelligence, that is:

a. Self awareness
b. Self regulation
c. Motivation
d. Empathy
e. Social Skills

15. Knows what research they have done and how they plan to continue and fund it
16. Has a clear potential to become a mentor and leader for others
17. Has technical and academic skills that complement what they already have
18. They are not looking for an employee. They are looking for someone who will be part of their team and work together for better patient care.

SECTION IV: Physician Contract Basics

There are several elements all contracts should contain. These include the offer for employment, compensation, and contract duration. There are many sub-parts to these elements that come into play. This introduction will give you a working knowledge of the components commonly involved in an MFM contract. It’s important to note that state laws vary on many of these elements, such as general employment law, termination of an employment relationship, restrictive covenants, and personal liability, to name a few.

Contract negotiations can sometimes become an emotional endeavor if one side thinks the other side is being unfair. If you decide to negotiate the terms and do a bit of hard bargaining on your own, the other party may think, “If he/she is acting like this now, what will he/she be like to work with?”

Hiring an attorney who is familiar with contracts can be a good option. Having a lawyer represent you may take you out of that loop and allow you to get more favorable terms. However, having a lawyer make wholesale changes to a contract may also be looked at poorly. You have to remember that when you hire a lawyer, he/she is your ally and your representative. Your replies should adequately represent the conversations you have had with practice and previously agreed upon. It is also extremely

crucial that you have a lawyer who has previously represented physicians in contract negotiations. In university jobs, most of these contracts are university-specific and standard. The offer letter from the chair is where the specific details should be. It is always better if the offer letter is signed by more than the chair (Division director, Dean)

To start, remember that many issues are negotiable. Equally important is the rule that if it isn’t in your contract, then it doesn’t exist. If you’ve discussed something, even emailed back and forth about it, but it doesn’t end up in your contract, there’s virtually nothing you can do from a legal perspective after you’ve signed a contract. So make sure if you request something, it gets in the contract.

For most university positions, hiring a lawyer to do the negotiations is not helpful as the non-compensatory portions of the contracts are standard for the institution. In some situations, a recruiter may provide the same buffer as a lawyer between you and the person you are negotiating with at the academic institution. It does not hurt to have a lawyer look at the final contract before signing it, knowing that very little can be changed. The majority of the information below is for community-based jobs. Some of the components below may be negotiated for university positions and can be included in the offer letter. The following are ones to consider including:

Job description
Performance metric
Salary/Bonus
Administrative time (attend conferences, research meetings, etc.)
Percent clinical, education (students, residents, fellows) and administrative time
Termination
Office space, furniture/computer, assistant
In-house and backup call
Moving expenses
Allocation account, startup funding, and yearly support for research

Basic Contract Sections

1. Job description

Should be specific to Maternal Fetal Medicine (see MFM Job Description on SMFM Website)

2. Performance metrics

Are there surveys of patients, other doctors, and employees?
Are there requirements or incentives for research and paper production?
Is clinical productivity measured via RVUs, charges, and collections? Different activities will yield different RVUs (e.g., ultrasound versus on-call), So remember that what you are assigned to do could impact your apparent productivity.
Is there teaching of students and residents, and are they surveyed?

3. Salary/Bonus

How are you paid? Monthly? Bi-Weekly? When are bonuses paid?
C.O.L.A. cost of living adjustment. Is it part of a multi-year contract?
Are there bonuses for research, teaching, patient satisfaction, and clinical productivity?

4. Partnership
The key here is what is the track for partnership in the agreement, if any at all. Is there an opportunity to buy into the practice for collaboration? Or is it a matter of years spent with the practice? You should have a provision that also ensures you will have access to the financial statements of the practice at the time when the partnership will be seriously considered so that all parties have equal information during that process.
5. Non-compete clause
These are also referred to as restrictive covenants. These are wordy paragraphs that protect the practice if the employment relationship is terminated. The clause will basically state that after your employment ends, for a period of time (usually 2-5 years), you agree not to practice within a certain geographical area or within a certain radius of the employer. Often times in Maternal Fetal Medicine, patients are referred to a specific doctor rather than to an institution or practice. Naturally, the thought here is that patients will only go so far to see a doctor.

From the hiring practice/hospital/university point of view, they spend a lot of money in recruiting a physician. For this reason, these clauses are standard in almost all physician contracts, including MFM, to protect the perceived interest of the employer. The range of the restriction varies greatly from state to state, and courts have generally held that these are enforceable as long as they are reasonable in duration and geographic limitation. The laws here are generally governed by state law, which an attorney can easily research. Lastly, certain federal laws such as STARK also come into play in certain situations, primarily when a hospital is recruiting a physician.

6. Benefits and vacation time

401k, Medical Insurance, Dental Insurance, Continuing Medical Education Expenses, Cell Phone, Dues and fees for Society Memberships, Book Allowance
The typical package of benefits for a new associate physician includes health insurance (family coverage), legal liability (malpractice) insurance, dues, licenses, journals, and CME costs, or a portion of these. In addition, the practice will typically provide a vacation time allowance of 3 to 4 weeks for an associate, plus a week in each year for continuing medical education. There may also be a separate provision for sick pay at 5 to 15 days per year; to be used only as needed.
Alternatively, many practices now are shifting to the Paid Time Off (PTO) model, where you are granted around 3-5 weeks of time off per year, regardless of the reason for being off.

7. Termination
It is perhaps a bit odd to contemplate the end of an employment relationship before it even starts, but it’s prudent.

Termination Without Cause
Despite best efforts, sometimes things don’t work out. For this reason, you’ll want a provision allowing either party to terminate the employment relationship after giving notice. The standard for notice ranges anywhere from 30-90 days. As a physician, this is important for you to have in the contract for those rare moments when your life must take you somewhere else. If this option isn’t available, you may be liable for damages sustained to the practice because you haven’t fulfilled your contractual obligation, if for some reason you must leave. Similarly, if your employment is terminated, you will want to have some time to find another position. How about the employer being responsible for paying you in case of termination without cause?

Termination With Cause
These clauses, known as “For Cause Termination,” “Termination With Cause,” or “Immediate Termination,” allow the immediate termination of a physician’s employment if certain events occur. You’ll want to make sure these circumstances are clearly delineated in the contract. These include things like:

The MFM losing their license to practice medicine, or restrictions on their license to practice medicine;
The revocation or suspension of a physician’s right to participate in Medicare, Medicaid, or other governmental payor programs;
The inability of a physician to obtain or maintain malpractice insurance
A physician’s refusal to comply with workplace policies relating to substance abuse, sexual harassment, other unlawful harassment or discrimination;
The conviction of a misdemeanor that will affect the physician’s ability to carry out their job
The conviction of any felony

Lastly, there is usually a “catch-all” provision that states any act or omission that is harmful to the employer may be grounds for immediate termination. In clauses like this, there is usually a “cure” period in which the physician can take corrective action to cure the wrongful acts or omissions. Cure provisions usually only apply to minor infractions, not things like loss of a license, which would cause immediate financial harm to an institution.

8. What happens if you leave or are fired

Will you have to pay back certain expenses?
Will the employer cover the cost of legal liability (malpractice) tail coverage?

9. Office space

Will you be provided with office space?
Where will your office be located?

10. An assistant
In some settings, an assistant will be provided, but most of the time, shared staff will take on duties such as filing, dictation, answering phone calls, etc. If you are promised a dedicated assistant, again, make sure it’s provided for in the contract.

11. Work hours
Understand the general office hours and how time will be split between physicians if there are multiple locations. The needs of the patients often determine this, and it’s well-known that this can vary on any given day. There should, however, be some general expectations of office hours and availability of the physician in this section.
12. Night/On-call requirements

Will the MFM be required to take calls, how is it rotated among physicians, and how often?
Is night call paid for separately, or is it included in the salary? You may desire to define the number of nights/month if possible.

13. If you do extra work, do you get paid for more – how are you compensated
This, again, is dependent on the needs of the practice but should be contemplated, especially in a private practice setting. Understanding the expectations for clinical activities and having these documented in your contract is helpful.

14. Intellectual property
These clauses used to be only found in contracts of MFMs who went into an academic setting. These days, it’s standard practice to have a “Work Product” clause that states in the course of employment, all work products created by the employee will belong to the employer. If you have a related business or affiliation with another institution or entity, you’ll want to make sure you specifically exempt your outside work done as separate from your employment agreement.

15. Legal Liability (Malpractice) Insurance
This is a large expense that physicians naturally anticipate will be paid by the practice. Know the basics and what is most common in the jurisdiction where you will practice. In the MFM sub-specialty, the most common policies cover limits of $1 million per claim and $3 million per year.
The two types are Occurrence Based and Claims Based coverage.

Occurrence policies cover injuries that occur only when the policy is active, regardless of when the claim is filed. As a result, tail coverage (insurance for claims filed after you terminate employment) is not needed.
Claims-based coverage is more common and used in almost all practices nationwide. The physician is covered for claims that are made when the policy is active. Claims made after that time will not be covered. As a result, tail coverage is needed to protect the physician if claims are filed after the policy ends (usually due to the physician no longer being employed by the practice)

Tail Coverage can be very expensive and should be outlined in the agreement either in the termination section or in the professional liability insurance section. The common way tail coverage is handled in an MFM contract is if the termination is either for cause or if the MFM voluntarily leaves without giving proper notice (30-90 days), then the MFM is responsible for tail coverage. If the Employer terminates the employment relationship without cause, they are responsible for tail coverage. Many practices now consider a split of tail coverage under both circumstances.

16. Moving allowance
Most contracts will provide a moderate moving allowance. Make sure this is clarified before you incur moving expenses.

17. Signing bonus
This varies greatly from none to a significant incentive. The value of the signing bonus will depend on a variety of factors, largely related to local market forces.

18. Arbitration clause
Many contracts will include an arbitration clause directing both parties to submit their complaints to arbitration rather than going to court. This is usually done in accordance with the American Arbitration Association (“AAA”) rules and is held at the employer’s location. The benefits to the MFM are that it’s usually cheaper than going to court, and all claims made through arbitration are confidential, as they are not a part of the public record as most courtroom proceedings are.

Special Note: We thank Omen Safavi, Esq., J.D., for his help in this section.

SECTION V: Current and Future Influences on Employment

One thing that is certain is that there will be continued governmental and, hence, private pressure to decrease reimbursements for professional services. This will occur regardless of healthcare reform. In 2010, healthcare expenditures consumed 17.3% percent of the U.S. GDP. Medicaid currently funds more than 40% of births in the United States. Our country has a national debt that is approaching our yearly GDP. There are multiple inefficiencies in the delivery of healthcare.

It is clear that the place where pressure to decrease reimbursement the most in MFM will be in the field of ultrasound. The average patient in the U.S. has approximately 5-7 ultrasounds during a pregnancy. Additionally, obstetric ultrasound is currently the only radiologic procedure group that does not incur multiple procedure reductions. Multiple procedure reduction is the process of decreasing reimbursement for each code performed during a single visit; the first code is reimbursed at 100%, the second at 50%, the third at 25%, and the fourth at 10%. For example, currently, if multiple procedures are done (e.g., ultrasound for growth, umbilical artery Doppler, and a BPP), all are reimbursed at 100%. Under multiple procedure reduction, this would reduce reimbursement for the second and third procedures. There appears to be a current impetus to apply multiple procedure reduction schemes to reduce the costs of obstetric care. This would dramatically decrease reimbursement for MFM services and make the future of some solely prenatal diagnosis-based practices more difficult.

On the other hand, maternal mortality and morbidity in the U.S. are increasing, and in many cases, MFMs have been performing less inpatient work - leaving this to other specialties. There is currently a drive within the sub-specialty to re-emphasize fellow education in maternal care. Becoming comfortable with high-risk maternal obstetrical problems will become more important over the next decade, and it is strongly recommended you develop these broad-based skills. You will likely need to obtain and maintain clinical skills in maternal care as well as prenatal diagnosis to stay clinically and financially relevant as an MFM sub-specialist.