Central Line

Episode Number: 139

Episode Title: Physician Employer Relationships

Recorded: July 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ZACH DEUTCH:

Welcome to the Central Line podcast. I'm Zach Deutch, your guest host for today's episode. With me today is Dr. George Tewfik, the guest editor of September's ASA Monitor, which explores the topic of workforce and the pivotal relationship in the workforce between employer and employee. That will be our topic for today as well. And we're going to get started. George, welcome to the show.

DR. GEORGE TEWFIK:

Thank you so much for having me.

DR. DEUTCH:

And we're glad to have you. Before we get started onto the bones of this topic, can you just tell us a little bit about yourself and why this topic is important to you?

DR. TEWFIK:

Of course. I graduated from Rutgers New Jersey Medical School for my anesthesia residency. Uh, for my first job, I went to work with a large private practice group at a community hospital, and during my four years there, I completed my MBA at Rutgers Business School. Uh, after that, that group was sold to one of the large national corporations. I spent another about a year and a half with a very small private practice group. And then for the past seven years, I've been back at Rutgers New Jersey Medical School, where I'm an associate professor in the Department of Anesthesia and the director of quality assurance, as well as clinical informatics.

So I think that the reason that this topic really spoke to me and was something that was really important for me to explore, is that I have experienced different employer employee relationships. Like I mentioned, I started in a large private practice group. I saw that transition to a large national corporation that works in anesthesia. After that, I experienced a very small private practice group that was less than a dozen people, that was managed by those senior partners. And now I'm in an academic practice model which has a bit of a private practice feel to it, while still being obviously an academic model.

Other than one's family and friendships, you spend probably the most of your time at work, so that employer employee relationship really can dramatically impact your life in a myriad of ways, starting with job satisfaction, but really moving throughout your entire life. And I've experienced good relationships and bad relationships through my colleagues and friends. I've seen how good a relationship can be between employers and employees, and what happens when it turns sour for a whole host of different reasons. So again, for that reason, that's really why I was interested in exploring this topic more in depth.

DR. DEUTCH:

And it's nice to see that you have a range of experience between the academic and the private sectors. So that's always refreshing and really informs the discussion. I think more than people that have a more narrow perspective. And on the show before, I talked about the shift toward employed models of practice, whether it's hospital-based employment or work for large healthcare systems. So can you give us your thoughts about the pros and cons of that situation for clinicians?

DR. TEWFIK:

So this transition is really happening not just in anesthesia but really across medicine as a whole. These smaller private practice models, even in surgical groups, which were kind of thought to be the one last holdout, are getting purchased by large private equity backed corporations or by hospitals or by healthcare systems or even by insurers in some cases. And there are pros and cons, I believe, to any one of these various practice models. I think that the trend seems to be moving in that direction, seemingly primarily out of financial concerns. We had, especially following the pandemic, a great shortage of clinicians throughout all of medicine. There were a variety of reasons for that, including retirements and burnout. And as that happens, there was a greater need for clinicians, and that caused financial pressures on those groups. And it became seemingly much more important to have a large player behind you, be that a hospital or a private equity backed corporation or what have you. And I think for those pressures, it really has pushed people towards, you know, teaming up with either other practices or, like I said, those larger organizations.

The nice thing about that kind of an organization is you're removing the day to day financial, administrative, regulatory pressures from the clinicians who now can really focus on patient care, staffing, the day to day, the nitty gritty that we're much more accustomed to than worrying about is my stipend large enough from the hospital? Am I getting reimbursed at a fair rate? You know, considerations such as potential cuts to reimbursement from an insurer's either public or private. So it really does lessen the administrative burden on those groups.

On the con side, when when you're potentially giving up the private practice model moving into a large corporate model or a healthcare system based model, as expected, you're going to give up some autonomy. Um, you're going to be, uh, at the mercy of requirements to cover certain staffing ratios or to cover certain locations. If your practice wants to expand, to cover a surgery center, that may be encouraged or discouraged. So it does lessen the control at the local or departmental level to some extent, but it expands the abilities, potentially to have a more comfortable practice in which you're not worried on the day to day, like I said, from those financial, regulatory, qualitative burdens.

And of course, there's a whole host of other pros and cons with these types of models that must come into consideration. But just on a on a global macro level, those really are the main driving factors and considerations that groups and clinicians and practitioners are experiencing in this transition.

DR. DEUTCH:

That's a very extensive answer, which is thoughtful and appreciated. I want to focus in on kind of one aspect, which is the financial aspect, and talking about the transitioning of practices to an employed model via the selling of the practice, which would be more commonly to a national practice or private equity firm, and less commonly to a hospital. Can you give us some commentary on that trend?

DR. TEWFIK:

Yeah. It's interesting. Within the past ten, 15 years, there really was a pickup of private equity backed corporations coming into anesthesia and purchasing practices. It was the same sort of potential pressures that were being alleviated in those kinds of transactions. When a national partner comes in, they're able to assume the day to day financial responsibilities, regulatory, qualitative. They're able to potentially make investments in improved IT and quality reporting. Interestingly enough, in the last few years, at least in the coastal regions, we're seeing a bit more of a pickup towards hospital-based employment versus that trend. Which is not to say that the PE backed corporations are not still acquiring groups or are not still a major factor. They are. There are several very large private equity backed anesthesia corporations throughout the country, and the same kinds of pressures that had facilitated the increase in purchases starting about ten, 15 years ago still exist today. There's still tremendous financial pressure in the anesthesia world, potential pending cuts in reimbursement due to the Medicare adjustment values and insurance rates when they're tied to that could cause tremendous financial pressure. So there are still those same kinds of pressures, which were, of course, exacerbated following the pandemic. But we're also seeing a bit of a transition towards hospital-based employment. And those same kinds of pressures are causing people to to want to team up and to move towards having a larger partner.

When you're considering the sale of a group to a private equity backed corporation, you are talking potentially about a large cash or stock type of transaction, and that allows the physician partners who spent potentially years building a practice to cash out some of that equity that they've built up in their practice, and to be able to potentially, you know, invest in their own manner afterwards. You don't necessarily get something like that when you're talking about acquisition by a hospital or health care system. So that's obviously a major consideration for physicians who are considering that type of acquisition as well. Um, we're still seeing major players in the private equity backed corporations, and I don't think that that's a trend that will abate any time soon. I think that overall, across anesthesia and across medicine as a whole, the day of the the solopreneur or the small, scrappy little practice that maybe we grew up envisioning when you turn on a classic 50s or 60s sitcom, it doesn't really appear like that model across medicine anywhere really, is still a major factor in our health care system as it is today.

DR. DEUTCH:

And speaking specifically about hospital-based employment, which you touched on, just sort of want to explore what might be the hidden positives of that, because I think to a lot of people it seems initially negative. You know, hospitals don't know how to run periop properly. We have to show them. But again, as you say, this is an increasing trend. So could you give some more insight into people that might end up in that situation or contemplating that situation, that these are the true realities of what it might entail? Sure.

DR. TEWFIK:

So like I mentioned, this is a trend that's seemingly increasing across the country especially it seems like in coastal areas or the northeast, it's a trend that we've seen. It looks like again, it's it's a financial consideration. But a lot of times it's important to consider that in order to remain financially solvent, hospitals, health care systems often need to provide a financial stipend to anesthesia. For example, if you require 24/7 in-house coverage but don't have the caseload to be able to sustain that with your manpower, that might require a hospital subsidy. As you can imagine, that becomes a point of contention and negotiation and back and forth between private practice groups or PE backed corporations, either or, that are negotiating with the hospital or health care system. But in order to be able to increase their surgical services, their radiology services, their interventional services and scopic services. The hospital needs to be able to guarantee to those proceduralists that anesthesia is available. So, you know, it's kind of a catch 22 between both sides. We really do need each other. It's just about kind of figuring out where that number is in order to ensure the adequate anesthesia coverage for the proceduralists and the surgeons.

So it seems like the hospitals, by directly employing the anesthesiologists, are removing that factor. So they're removing the need to provide a hospital subsidy. And by directly employing the physicians, they can guarantee a certain level of service for the patients and the physicians in their institution. So it's it's a really interesting trend. It's not wholly new, but it does look like it's it's something that's somewhat accelerating depending on the geographic region. And again, the hospital-based employment, just like partnering up for a larger practices, is a trend across medicine. The trend toward hospital employment seems to be picking up across medicine as well. You see a lot of hospitals and healthcare systems bringing the surgeons in, bringing the private practice, Um, you know, family medicine physicians and and the internists and the pediatricians and bringing all those services in and then bypassing any sort of alternate financial arrangement that they might need to make in order to ensure an adequate level of coverage for their community.

DR. DEUTCH:

And to that point, the health system I'm working in, currently, 95% of the Proceduralists are employed by a private health system. And it's interesting because I wonder sometimes, you know, everybody wants to own the orthopedists so that the structural heart people are the people that are doing things that are lucrative and they want to get more than their share of just the facility fee. Right. But then I wonder sometimes when hospitals go for anesthesia groups and really get into the true economics of perioperative medicine, if it's a scenario of be careful what you wish for.

DR. TEWFIK:

It very well might go that way. The groups that are experiencing this in my part of the country, in the northeast, it's a relatively new trend that's occurred over the past few years, and I don't think we've seen the long term economic implications of this. Staffing across anesthesia has been so tight, especially since the pandemic that it might cause a somewhat temporary alteration or disruption in what the true economic state of perioperative medicine is. So I think it might take a couple more years for the economics of these new trends to really shake out, and for hospitals to be able to step back afterwards and say, this does make financial sense for us. This does not. This is an arrangement we'll continue moving forward with or not. Or maybe they'll look for alternate arrangements at that time. But yeah, it's it's definitely something that I think is is still evolving. I think we're still only starting to see the beginnings of the long-term economic outlook for models like this.

DR. DEUTCH:

George, it's been great talking to you so far, and I'm sure listeners will be really interested to hear more of what we have to say. We have much more to touch on, but for right now, we need to take a short break. Listeners, please stay with us. We'll be right back.

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DR. KANTZ:

Hi, this is Doctor Kimberly Kantz. I'm the vice chair of equity, diversity and inclusion at the University of Pittsburgh Department of Anesthesiology and Perioperative Medicine. We all want to live and work in a culture where we are appreciated for our contributions and feel supported. Applying the principles of diversity, equity and inclusion, or Dei to perioperative care to not only improve work productivity and satisfaction, but also patient safety and outcomes. You can start applying a Dei lens to enhance patient safety today. First, take a team approach to patient safety, including people with diverse perspectives and lived experiences to spot biases and address barriers in creative ways. Second, implement translator services, a standard of care. This can help patients feel valued and facilitate trust, communication, and satisfaction, all of which are important for patient safety. Third, access and analyze demographic data when assessing safety metrics to identify disparities that need to be addressed. Incorporating Dei principles into your everyday practice can help address patient safety challenges.

VOICE OVER:

For more patient safety content, visit asahq.org/patientsafety.

DR. DEUTCH:

Okay, we're back with Dr. George Tewfic. I want to do a slight digression here. I don't want to get derailed from our topic because we've really covered so much ground and there's more to cover, but unionization is obviously a very hot topic in medicine. George, I'd like to get your opinion about how you think this might fit into perioperative medicine and the professional role in the future of anesthesiologists.

DR. TEWFIK:

Yeah. Thank you so much for that question. It's definitely a trend that, um, I think a lot of us in the anesthesia field are monitoring with great curiosity. A lot of physicians in the country are obviously not part of unions, and we hear a lot in the news and throughout conversations, even around the water cooler, about the potential of unionization to transform at least some parts of medicine. I think it moves towards the overall trend in people partnering up however. As I mentioned, there seems to be a lot of pressure on solopreneurs and small groups to team up. Be that with a private equity backed corporation, a hospital or a health care system. And I think that as physicians move towards those employed models, you know, especially with very large employers, there might be a seeming loss of the ability for negotiating power. And so I think unionization I don't obviously want to speak for the physicians involved directly in those situations, but it seems to be one methodology by which negotiating and bargaining power might be commanded a bit better by the physicians. Whether or not that continues to be a trend, I think really remains to be seen. There were, you know, the ones that broke through the news, I think had unique potential implications and unique considerations in those situations. But I definitely think it'll be interesting to see, especially as, as we mentioned before, more and more physicians throughout medicine, not just in anesthesia, are becoming employed by large employers. This might be one path that physicians use to move forward in order to improve their negotiating power.

DR. DEUTCH:

And I can't help but think, um, when we talk about any type of collective action and the implications of that, that this doesn't have something to do with the generational change in the workforce, the 50s and 60s ideal that you alluded to earlier of, you know, work, work, work, make money, careers first. I don't think that's extremely popular anymore. And it seems to be certainly going by the wayside by the next generation of clinicians.

DR. TEWFIK:

Yeah, it's definitely a big change. When the last couple of generations came out of their residency programs, it wasn't unusual to pick up a partnership track position where you put in several years of work and then you earn, you know, a share of a private practice. But for the last few years, I think this current generation and future generations of anesthesiologists who are graduating their residency will not necessarily ever come across a job with a partnership track, so they will spend their entire career as full employees. So that might be one of the things that's behind the impetus to join a larger organization for collective bargaining.

DR. DEUTCH:

And when we talk about the work itself, the one thing that is a constant, obviously, is the need to do the work and to have people to be there in the operating rooms in other areas. So staffing models are very important, especially now when, as you've alluded to earlier, mentioned, that there are not as many people in the mix. So we see a care delivered in a variety of models, you know, ranging from solo practice to care team practice to even supervisory type of practice. Can you give us your thoughts on those models? You know, kind of their their prevalence, pros and cons, and how they impact our own scope of practice in perioperative medicine.

DR. TEWFIK:

Of course. So there are a whole host of factors that go into a department or a group choosing their staffing model. It might be easiest on a macro level to just think we're going to consider this from availability of staffing and finances to to optimize our revenue share. But in actual practice, there's so many more considerations to the choice of staffing models. If you're working, for example, at an academic institution, you've got residents who might need to be relieved for lecture or for simulation activities. If you've got another location in which the surgeons are used to practicing, uh, with an MD only model, uh, then you might be, uh, in a situation where even though it looks on a macro level like CRNAs or AAs might improve the staffing that that they're not practicing within that department. So a lot of times it's it's based really on the realities on the ground as well as a cultural divide. And then of course, there's regulatory things like anesthesiology assistance may be available in one state and not in another. So there really are a whole host of factors that affect a department's staffing models. And it really is a conglomeration of those. A lot of times it ends up even really being that's just the way things are done here. And that ends up being really the staffing model. Like some groups that remain MD only, even though they might benefit from CRNAs or anesthesiology assistance to improve their coverage, or that they're short, Um, or another group in which they're struggling to find CRNAs or AAS and are unable to hire additional practitioners to to help staff. But, um, there's so many different factors that come into play. And even though a lot of times from an objective global macro standpoint, it might just say you've got 20 locations, staff it this way; you've got five locations, Staff it this way. You really got to think about educational factors, regulatory compliance, and cultural factors as well.

DR. DEUTCH:

And everybody's got a very strong opinion on this subject, from everything under the sun to the ratios to what they prefer, to what they want to do. And so it's very kind of difficult to have these discussions without them becoming sort of heated and emotional. The biggest peril that I see is not determining locally, as you talked about, each local environment may be different. Surgeons may really want to see 1 to 1 contact with an anesthesiologist their surgery center. They may not want AAs or CRNAs. These are all local things, but when the control is taken away, when someone tells you this is how you must practice. I think this is when we get a lot of trouble and people become very resentful.

DR. TEWFIK:

Yeah, of course, that's one of the difficulties in the environment that we're in with the shifting employer employee models that we've been discussing. You know, control is oftentimes one of those things that you do give up when you partner with a larger PE backed firm or a hospital or healthcare system or an insurer. You know, there are pros and cons to everything. And, um, depending on the arrangements between those physicians and that larger group, you know, they might have local control over staffing and they might not. Some of those larger groups come in and they say they're totally hands off. You make those kinds of decisions on a local level, and then some come in and say how we do it here is how we do it everywhere. You know, those are the kinds of questions that the partners in a practice might want to ask or consider before those partnerships do come into play, because those kinds of things really do affect your day to day job satisfaction or ability to do your job. Um, as we mentioned at the beginning, the reason I was so interested in this topic, um, is because other than family and friends, your relationship with your employer does determine so much of your day to day job satisfaction and happiness. Um, And if you're in a staffing model that you don't like, um, that could be something that really affects your ability to not only do your job, but enjoy your job. Some people are very happy and MD only model doing their own cases, and some enjoy supervision with CRNAs, and some enjoy teaching and supervision with residents. So it's not a one size fits all. And if those kinds of things are important, consideration for you as you look for employment as a new graduate or someone moving or what have you, that might be an important consideration when considering new employment.

DR. DEUTCH:

And of course, there's even more nuance to that, because you might have the ideal practice environment, but it's 30 minutes from your house and there's a place that's right across the street. And, you know, these are things that also play into what we do. Uh, and so very complicated. And also, as we say, people tend to become very opinionated about these matters. So, you know, we just do the best we can. But it is not an easy thing to navigate. I think, given all the external pressures and the lack of individual choice, that sometimes occurs for a variety of reasons.

DR. TEWFIK:

Yeah, definitely. I mean, there's so many considerations when, uh, thinking about whether or not to take a job. And all those things really do do affect your ability to do your job and your job satisfaction. And as you mentioned, people do get heated and opinionated, especially when there's transitions. You know, if if you are transitioning the owner of the group to a larger entity, and, not only that, but also changing staffing models. That could be a tremendous shift in the culture of a department and the culture of a group, and really might not be something that that people tolerate well, or it could be something that becomes incredibly beneficial for a department, and they're seeing a new way of doing things. It's very difficult to anticipate how people are going to react to large changes like that.

DR. DEUTCH:

Well, while we're on the topic of physician’s aggravation, I'm going to mention a topic which is a potential not necessarily real aggravation, which is quality metrics, which we often see used by administrators and health systems as a component tied to compensation. How might these be used by employers to kind of index their employees efficacy? And do you feel like that is a worthwhile endeavor? Does it really have value?

DR. TEWFIK:

Uh, so this is something that we're seeing more and more as I talk to our residents who are considering employment. Patient safety and quality metrics, uh, are becoming more and more important and are often used as a factor in physician compensation. So we're seeing that our residents, for example, are getting offered employment contracts with those kinds of stipulations. So quality and patient safety as we all know, is critically, critically important. Anesthesia has always been a pioneer at the forefront of patient safety, from Dr. Apgar to the advent of the pulse oximeter. That being said, it's it's really difficult. How do you determine what is a quality anesthesiologist? I always go back to a story or a comparison that someone asked me a long time ago, is, would you prefer a surgeon who has a 0% morbidity rate, but only chooses the most stable or most ideal patients? Or do you want one with a two, three, four, or five percent morbidity and mortality rate but who doesn't choose their patients and operates in the most difficult of environments? And we see the same kind of thing in anesthesia. You know, you get the cases that you get and sometimes there are bad outcomes. But overall anesthesia is incredibly safe. So what kind of quality metrics do we really want to look at to evaluate how good a clinician's care is? Do we want to look at things like morbidity and mortality? Do we want to look at morbidity and mortality, and consider whether or not there was a deviation in scope of practice or care? Do we want to look at quality metrics like checklists or ensuring metrics like post-operative nausea, vomiting, prophylaxis and preoperative antibiotics administration? Um, when we get into quality metrics and saying that there is a component of your evaluation in and of itself, that a lot of times can cause consternation amongst clinicians, but then when you're also tying, um, you know, productivity based bonuses and compensation to it, it can get incredibly heated. And then we're not even getting into some of the most potentially fraught metrics, including patient satisfaction. You know, a lot of times, the surveys that we get back from patients and the family members are incredibly skewed because the only people who took the time to fill out the survey are the ones who were incredibly unhappy with something. And a lot of times it doesn't even have anything to do with anesthesia care. The pre-op nurse wasn't nice to them, so they say anesthesia care was terrible. You get things like that all the time. And when you see a metric like that, how is that potentially going to fit into assessing an individual's quality? So these are incredibly fraught and incredibly difficult.

And what I always advise our residents when evaluating a contract is that, especially if this is a sizable portion of compensation, to really understand and to to really drill down and anticipate as to how these are going to play out and to see how they work out in practicality. I advise our residents to speak to a lot of people at a new job, speak to the last couple people who are hired at a practice, and how do they feel about, you know, things like compensation and daily work hours and call burden, but then also something like this, again, if it's a sizable portion of compensation, it might be worthwhile to ask someone, hey, how does the quality metrics bonus work out? What are they basing it on? Is it something that within our control, something like antibiotic prophylaxis and following the skip protocol and following time outs or, you know, compliance with documentation, or is it something that's potentially out of our control, like patient satisfaction surveys? These are the kinds of considerations, again, a lot of residents are not thinking about it when they're looking at their first job, a lot of mid-career or late career anesthesiologists may not think about it as they're switching jobs, but these are the kinds of things, especially as throughout medicine, we're really, really shifting towards improving quality and patient safety. There is a variety of different ways that these kind of metrics can be calculated to evaluate individuals performance. And then from there, there are a variety of different ways how it could be used to affect evaluations and potentially compensation.

DR. DEUTCH:

And this is a little bit off the thread of what you were talking about but you made me think about this when you were giving advice to people seeking jobs to make contact with the recent hires and such. And I'm thinking of a position I applied for years ago where I met a guy who was basically said, well, you know what? This job is really not that good, but it's really close to my house. I've been there for 15 years. I know everybody, you know, I'm just kind of inertia is carrying me to the end of my career. And I guess you really hope, whether good or bad, when you seek that type of feedback, you get that level of honesty, because that actually really did help inform my decision in that situation.

DR. TEWFIK:

Um, yeah. The people who are bringing in recruiting you, um, for a job, um, are not necessarily going to be neutral arbiters telling you the truth. Uh, but the last couple people who were hired or someone who's just on the ground, um, you know, in the hospital doing their cases, maybe not necessarily involved in the hiring decisions, um, you know, they might be able to tell you much better. The calls are not that bad. Oh, the calls, you know, you get beat up a little bit. They might have much more honest feedback to provide. And there's only so much you can get from talking to the hiring director of a group or from reading a contract. A lot of times, the practical day to day nature of how a job actually functions might be something that you can only glean from talking to a lot of people.

DR. DEUTCH:

And so you've mentioned that magic word a few times, which is contracts. Let's talk about that. What should physicians be looking for these days in contracts? The usual, the unusual stuff that might trip them up. Stuff they need to be aware of, just any sort of general advice you can give, which I think would especially be useful for people starting their career.

DR. TEWFIK:

Of course. Um, as my departmental contract liaison for a lot of our residents, as I mentioned, I always give the first disclaimer is that I'm not a lawyer, and I think it's super important when you're looking at an employment contract to have an employment labor lawyer review your contract. So this is not legal advice and I advise everyone out there who's listening to get proper legal advice when reviewing an employment contract. That being said, you know, these contracts are oftentimes very difficult to read and have a lot of clauses in them. And, you know, it's so exciting when you get your first contract. I remember getting my first employment contract. And like a lot of the residents, I'm sure today, you see the the number for the salary and you see how much extra calls are going to pay you and you see your number of weeks of vacation. And really, beyond that, it's easy to get lost. You know, you might have another ten, 15, 20 pages and you're like, oh, I'll figure out the rest of this later. But there's so many important things. And as the relationship between employers and employees is changing, even the things that were standard language a few years ago are changing in and of themselves. If you just take a look at the things that have been happening this year on the national stage, um, the Federal Trade Commission banned non-compete clauses. And then after that happened, there was discussion about whether or not that would apply to physicians or professionals, or it would just be limited to hourly workers. And then after that discussion, there was talk of whether or not this would apply for employees of nonprofits. And after all that was said and done, now you've got it being litigated in the context of the Chevron doctrine being reimagined by the Supreme Court, which potentially limits agencies abilities to interpret laws.That might have a tremendous impact as to whether or not non-competes are enforceable and still put into contracts. So just on this one little thing, which could have potentially huge implications for especially like a new resident coming out and picking that first job, you're talking about where you and your family might be able to live, and a non-compete could potentially affect your geographic location for 18 to 24 months after leaving a job. So just something like that, which might be a couple of lines in a contract, demand tremendous attention. So again, that's why I always advise, when you're looking at an employment contract to seek the advice of a lawyer, because not only is the relationship between employer and employee tremendously impactful on one's day to day job satisfaction and clinical satisfaction. But this is the pathway to that relationship. That contract is what dictates that future relationship and the nature of it and all kinds of life situations may change, for which there might be language in there that ultimately dictates how that is, how that is litigated and plays out. And, you know, small things like mandatory arbitration might be something that you read in a contract and say, I don't even know what that is, that I've never even heard that term before. But something like that could have tremendous impact on your ability to seek legal recourse from your employer later on. Really, I urge those who are evaluating their employment contract. Sure. It's super exciting. You see the big number. It's a big change from residency and fellowship. But don't focus just on those details, because specificity around so many different clauses in that contract could affect things like your ability to leave that job later on.

DR. DEUTCH:

Yeah, that's good advice. I mean, you know, we tend to kind of rush to the endpoint, and the endpoint isn't so clear now. And you need an expert to navigate it. You may not want to drop $700 or $1000 or whatever it is on a on a contract review from an attorney, but it seems like it's essential. I think you make really good points there and give good advice.

DR. TEWFIK:

Um, yeah. It's not an easy thing to seek someone out, but a lot of residences have resources within them that allow residents to consult with an employment contract lawyer, maybe potentially at a discount rate. But yeah, it seems like it's expensive now, but it might save you tremendous heartache or difficulty later on in your career.

DR. DEUTCH:

There's some words of wisdom for you. George, you've given us a lot of words of wisdom here and a lot of insight. We're coming toward the end of our session here. It's been really enjoyable talking with you. Having just been a guest editor of the Monitor. I just want to get your general feedback--anything surprising you learned from the articles that were solicited and and put together? Um, any real take home points you saw that were particularly noteworthy to you for yourself and for our listeners?

DR. TEWFIK:

I think what surprises me oftentimes the most is that it's very hard to generalize. People automatically say, hey, I'm interviewing for a job with this national corporation, or I'm interviewing for a job with this large health care system in this geographic region, and people jump to conclusions or make assumptions based on that practice model. You know, this type is good, this type is bad, and tend to globalize. But I think there's so much more nuance to this topic, and sometimes it can get lost in the discussion, you know, people's experiences at one large corporation at one institution might be very different from even that same corporation at another institution. Same thing with healthcare systems. It might be very different from one institution to the other. So I think the hardest thing might be to avoid putting practices or employment types or open jobs into a bucket and not keep an open mind. So I would I would definitely recommend, especially if you're looking to change jobs or to transition your practice to to keep an open mind and to try to understand as many different aspects of a job or what an employer's relationship is before you get into that kind of a relationship.

You know, it's one of those things that has tremendous impact, as I mentioned, in your life and going into an interview even with a preset mindset of this type of group is good and ignoring potential pitfalls that in and of itself can be dangerous. So I caution those who read these articles this month and are evaluating, especially looking at new employment, to to keep an open mind and to try to get as much information as you possibly can from as many sources as you possibly can, because it's very easy to globalize. It's very easy to put employers globally into a, you know, good or bad categories when there's really so much more nuance to this topic and to the practical day to day application in one's own career.

DR. DEUTCH:

I think that's very well said, because your comment about the inability to generalize, because I'm thinking, you know, you buy a Honda Civic or you buy a Kia Sorento or whatever you buy it's pretty much the same if you buy it in Alaska or if you buy it in Texas. But we have seen, and I can think of in particular, one hospital system and one physician service group that are nationwide that have a reputation here in Florida, which is quite different than the reputation that they have in other areas. So this idea that everything is local, I think is very pertinent, even though we would don't think about it that way intuitively. But it's true.

DR. TEWFIK:

Yeah. It's hard, you know, because people have their own personal experiences too. You know, you might be talking to a physician who had one bad experience with one type of employer in the past, and, you know, lambasts them and speaks ill of them. And that turns off people to that type of employment. But that's a localized experience. You don't know what the circumstances were surrounding that employer employee relationship. There are all kinds of local factors and local politics and local financial considerations that could affect negotiations between one group of physicians and a larger entity, and that's what caused the souring of the relationship. So my advice is to always keep an open mind and to consider each situation uniquely. You know, just looking at noncompetes, it's changed so much in the past year, we don't know what the financial landscape is going to be across anesthesia or how employment's changing even more and more in medicine. So much is changing and is so rapidly across our national health care landscape that I think going in, especially when you're looking at a potential new employer with an open mind, really is a tremendous asset to have.

DR. DEUTCH:

Well, George, it's been great speaking with you. I doubt that you will be lambasted. I think you'll be lauded for the contribution you gave today, giving us a lot of excellent insight. And it's been really a pleasure to speak with you, and I hope that listeners enjoy this podcast we've put together.

DR. TEWFIK:

Thank you so much for having me.

(SOUNDBITE OF MUSIC)

DR. DEUTCH:

And to listeners who want to learn more about this, go to asamonitor.org please tune in for the next edition. And we always welcome you and your input.

VOICE OVER:

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