Pursuing a medical career out of residency

I see two main income tracks that new attendings can pursue right out of residency, one is getting a traditional job and starting to make a solid income and the other is going out on their own.

This could involve either starting a private medical office or partnering up with other young doctors. But it could also involve getting into less traditional clinician jobs. The first job out of residency will set the tone for future career moves, that’s what this post will be focused on.

A buddy of mine pieced together multiple per diem gigs to build his ideal schedule for nearly 3 years after finishing residency. He got to enjoy a ton of free time, he traveled and this eventually allowed him the opportunity to get hired by high-end concierge medical practice full-time.

Your first job sets the tone

It’s not true for every healthcare professional but definitely for most, what you do coming out of residency or graduate training will set the tone for your future career opportunities.

Imagine a dentist who comes out and opens their own practice, finds themselves isolated and trying to learn everything on their own. With no other associates to bounce ideas off of and heavily entrenched in the entrepreneurial side of the business. They may not gain the adequate clinical expertise needed and regardless of how much they are making, the stress may catch up.

Why the clinical expertise? It’s not just so that you become a competent clinician but it’s also about your comfort level. Gaining adequate clinical expertise will drastically increase your comfort level in the healthcare setting which will lower your stress level.

Large medical Group

There is a huge argument I could make for why it’s beneficial to work for a large medical group right out of residency instead of going out on your own. These organizations are often risk averse and will have excess redundancy built into their system.

They will go out of their way to offer you training, to allow you easy access to specialists, offer CME’s and get you the tools needed to communicate effectively with staff, patients, and fellow clinicians.

Ignore the warnings

Many of us who attended big-name residency programs will undoubtedly be told by our program directors that we shouldn’t ‘sell out’ to large medical groups. That these organizations are in it for the money and that we will lose our skills.

So yes, I am recommending that if you are given a blanket advice against large medical groups, that you should ignore it. Of course, there are some horrible medical groups out there where doctors go to make a ton of money and lose much of their skills – do your research and skip them.

As a general rule, if you have to worry more about billing than the health of your patients and evidence-based medicine, it’s better to pass on the job.

Gain your expertise on their dollar

What I love about the larger, well-established medical groups is that they will spend a ton of money to train you. Southern California Kaiser Permanente, even calls their course the SCPMG University because it’s so involved.

You will have access to endless hours of online tutorials on managing disease, dealing with difficult patients, breaking bad news, dealing with coworkers, managing stress and avoiding lawsuits.

As a primary care physician, you will be able to dial up a specialty colleague and run whatever you want by them. In return, they will offer up their expertise and you’ll learn something new.

The big medical group will take care of a lot of the backend work such as billing, bringing in patients, dealing with complaints, providing supplies and handling your payroll. All you often need to do is show up – they’ll even have coffee ready for you.

You can also gain leadership experience on their dime. They will put you through leadership courses, teach you finances, tell you how operations work, teach you about human resources and allow you a ton of opportunities to move up the chain.

Deal with your immediate Red Flags

This is overlooked by many residents so let’s address career red flags here. I consider red flags to be anything involving:

• feeling burnt out
• severe depression
• suicidal thoughts
• major family issues
• personal health problems
• bewildered feelings towards medicine
• personal moral dilemmas

If you ignore these then they might disappear for a while, trumped by a very high paycheck, a lot more respect and an escape from residency. But they will resurface again, often much uglier than before.

If at first you were just feeling overwhelmed, helpless and out of control without any way to cope, leaving such feelings unaddressed could mean that you will develop some ugly-ass coping mechanisms such as abusing drugs & alcohol, abusing your body, taking it out on you loved ones, turning to gambling or illegal activities.

So, if you have major red flags then take some time off and address them. Avoid the big potholes such as getting a DUI or getting caught with a sex worker on a sting operation.

If you’re hating medicine…

“It’s just residency, once you’re out it gets better.”

This might be true for some but I find that most of my colleagues who had a miserable residency experience, had an even worse experience as attendings.

It’s like being in a shitty relationship and then deciding to get married or having a child together – it’s only going to get worse. A bigger commitment to an employer, more hours, more responsibility, and more money will not make things better.

Take some time off despite what everyone else says. Really take time off, tell yourself that it’s okay to be ‘lazy’ as long as you are productive. Read, write, spend time with family or spend some time living in a new place.

It’s easy to worry about ‘losing’ skills, it’s certainly one of my biggest fears. I recommend doing an excess amount of CME’s, reading some great books on your specialty and participating in specialty forums and wonderful websites such as Figure1.

Consider moonlighting if you haven’t already

My residency encouraged us to moonlight and I took up the chance to dabble in all sorts of different medical work. By the time I was looking for jobs in my chief year of residency, I had worked in 7 different medical settings. I knew exactly what I didn’t want to do, had a vague idea of what I wanted to do and knew what the minimum going rate should be.

There is no rush!

Dude, take a deep breath and relax! You probably went straight from high school to undergrad, straight to medical school and then residency. And now you’re about to go straight into becoming a career-doctor. What’s the rush? Just because you’re rushing doesn’t mean time will move faster. This is the time to loosen the belt, take a deep breath and explore.

What’s the rush? Just because you’re rushing doesn’t mean time will move faster. This is the time to loosen the belt, take a deep breath and explore. A lot of decisions will become easier and clearer.

If you didn’t get a chance to moonlight then find a few different gigs (not just one) and try them out. Don’t do this for too long because it’s important to find a job that you can feel dedicated to out of residency – I would say 1-2 years is plenty of time.

You could work just 20 hours a week, recuperate from residency with your free time and still make enough to make a dent in those student loans.

But there are no jobs after July!

Bullshit! Whoever said that doesn’t know how frequently providers turn over. Docs are fired, some leave, some retire, some commit suicide, others go on extended leaves… jobs are always available.

It’s okay to start as a per diem and wait for a full-time position. The larger medical groups bring on new-hires often through their per diem pool especially if they have been recently burnt by bad hires or because there are very few full-time positions and too many applicants.

Try to stand out

I will do a whole post on this because if you are at all interested in being offered a more permanent position then your performance as a per diem will matter greatly.

It’s not just the boss you have to impress, the nurses, co-workers, schedulers and HR staff are among the most important individuals who will be asked about you before you are offered a permanent position.

Where do you want to end up in medicine?

It’s important to give some thought as to how you want your lifestyle to look, how much clinical work you want to do, how much admin work you want to take on and whether you want to make as much money as possible or do the bare minimum to enjoy a comfortable lifestyle.

I beg you to ignore all your colleagues, all your program directors and anyone else who wants to paint you the ‘real picture’ of what the job market is like. Chances are they don’t have a clue. Unless a person is handing out resumes like candy on Halloween, it’s quite unlikely that they will have a realistic idea of all the options out there.

Start with your vision and work backward

If you want to work 4 hours in the morning and have the rest of your day off then start with that and try to build that kind of lifestyle. Don’t look at things from a standpoint of fear, instead consider the abundant work opportunities that are out there.

If I took an 8-hour telemedicine shift with Kaiser Permanente and called all my patients in 4 hours then I would have one hell of a productive morning and make $800 dollars for that day. If I do that every morning for 1 year then I would have nearly $300,000 of gross income for 28 hours a week of work.

Maybe you prefer to supervise PA’s or oversee residents and do research or admin with the rest of your time. If that’s the case then it’s good to figure that out now because you need to create the kind of resume that will get you a position like that in the near future.

I can approve medical marijuana cards for patients 1x a week, see 20 patients and make $4,000/month with only 4 hours a week of work.

If I answer questions on Just Answer for 4 hours a day then I could make around $16,000/month. All I would need is my laptop and an internet connection. I wouldn’t even need malpractice insurance for this kind of work.

Leave room for doubts

As you get older, you change. Your desires change, other people come into your life and your priorities shift. Perhaps early on the most important thing is to make the most amount of money possible to pay down your debt. Later, your priority might become having more time with your family.

If you start out wanting to be the director of a large medical group, you might find yourself emotionally depleted by the grueling work. That’s why I am saying that you should leave some room for doubt. As you get into the weeds you will discover more options and your career desires might change.

Be flexible and give new opportunities a chance. Sure, it can be a pain in the ass to have to fill out yet another application but it might be worth it in the end.

Finally, never, ever burn bridges. Maybe you applied for a position and it didn’t work out. If you and the employer part ways gracefully then chances are that more doors will open for you in the future through them.