It's a mad scramble for doctors in today's market; there's no doubt about it. The average physician candidate is job hunting with location, location, location driving the bus and compensation filling the tank.
For the job seekers I talk to every day, it's all about where and how much, otherwise known as “what's in it for me?” But what about “how can I help?” Or “where can I do the most good?” You might be surprised to hear that there are some wonderful opportunities for emergency physicians that include spectacular locations, very nice income, and perks to boot, at least for those willing to put the concept of service first.
There are 155 Veterans Affairs medical centers that provide care to our nation's non-active military personnel. The VA has 60 million outpatient visits a year. Certainly some VA facilities are higher tech than others, but all have a computerized patient record system that networks throughout the entire VA. They also have implemented the barcode medication administration system throughout their network.
The federal government accepts responsibility for negligence issues, providing a more favorable litigation environment for physicians. You only need one active state license to work in any VA facility in any state. You can start with a job in Reno, move to Spokane the next year, and to Lexington, VA, the year after that, all on that initial Nevada license. Federal government benefits include a variety of health coverage options, flex spending accounts, term life insurance, long-term care, and lots of paid leave, including up to 26 days of vacation, 13 days of sick leave, and 10 paid holidays. In addition, the VA provides a three-tier retirement plan that includes matched savings, such as a 401K. Career physicians who retire from the VA have their health care covered after retirement.
Salaries for emergency physicians begin with base pay and add two additional pay scales. Market pay is additional income commensurate with the specialty, the physician's credentials, and his experience. Performance pay depends on the assignment and the physician's performance. VA physicians also have a loan payback program and a relocation and recruitment incentive that can be up to 25 percent of salary.
I spoke with an emergency medicine trained and boarded physician at the VA who is involved with academic emergency medicine. He said he “gets a very warm feeling from working with these special patients who really deserve the best care and who always demonstrate their sincere gratitude.”
The Indian Health Service provides physicians to hospitals on Native American reservations across the country. The variety of lifestyles and cultures is staggering. The Navajo reservations in Arizona are significantly different from the Osage and Cherokee reservations in Oklahoma and the Cheyenne in South Dakota. In some cases, a physician can live on the reservation in subsidized housing, and experience these amazing cultures firsthand. The IHS hospitals are diverse and technologically advanced, staffed by physicians from top medical schools and residency programs. Michael Berryhill, MD, who works at the national IHS headquarters in Rockville, MD, explained that working for the IHS means working for the federal government, although there are some situations, especially in Alaska, where physicians work directly for the tribal medical service. In these cases, the job is like any other private sector position, with a Native American tribe as the employer.
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Ken Stewart, MD, a veteran IHS physician who has worked for tribes in Alaska and is now the emergency medicine chief for the Gallup (NM) Indian Medical Center, emphasized the wide variety of cultural and environmental options throughout the IHS. If you attend the ACEP Scientific Assembly, you can usually find Dr. Stewart staffing the IHS booth. Stop by to chat with him; I guarantee the experience will be rewarding.
Dr. Stewart started working with the IHS on a locum tenens assignment nearly 20 years ago, and stayed with it because the work was so gratifying. In an interview he did with ACEP News last October, he described the work as “outrageously interesting,” everything from hantavirus to snake bites to plague. Dr. Stewart emphasized that the IHS hospitals “resemble socialized medicine models of access to care. That means that people are eligible for care, so you don't have to fight about who is eligible and who's not or check their credit cards at the door. It's a complete system.”
Stewart Anderson, MD, a 2007 graduate, started with the IHS in Shiprock, NM, right out of residency. He is now an ED director. “I really love working with the Navajo people,” he said. “They are kind, patient, and appreciative as patients, and they approach the world very differently. Also, we have a very tight medical community. I live in government housing near the hospital, and am neighbors with most of the other FPs, internists, and surgeons. We know each other well so we treat each other well, and it really feels like we're working together. It is a true medical community.”
The Indian Health Service provides salaries along the same levels as the VA with base, market, and performance pay. Dr. Stewart, who volunteers as a recruiter for the IHS, said incomes are based on credentials, training, experience, and location. There are IHS emergency departments that require emergency medicine board certification and residency training, and they have higher salary potential than those ED assignments that accept primary care training and boards. The more years of experience you bring to the table can also increase the dollars. EPs in higher volume departments are often earning salaries equal to those of their private-sector neighbors. IHS physicians enjoy the full range of federal benefits including health care, paid leave, a three-tier retirement plan, expenses, matched savings, CME, and malpractice and tail coverage.
All IHS sites are now eligible for some form of loan payback, according to Sam MacBride, MD, a medical staff recruiter for the Northern Navajo Medical Center in Shiprock. The IHS Loan Repayment Program requires a two-year contract, and is renewable annually as long as you have eligible loans, providing $24,000 per year, though it is considered taxable income. The National Health Services Corps loan program is available at some sites and also requires a two-year contract renewable up to four years, but pays $25,000 per year as nontaxable income. Some states, including New Mexico, also allow enrollment in the state loan repayment program, which provides another two-year renewable $25,000 per year payback that is nontaxable income. Dr. MacBride said it's actually possible to get up to $200,000 in loan payback funds over a four-year period with dual enrollment.
If you are looking for perks, the IHS is offering recruitment and relocation bonuses in many of its locations. I did a quick search through its web site, and found opportunities in Arizona, Montana, New Mexico, and Oklahoma, just to name a few. There were also positions working directly for Tribal Medical Services in Alaska and in Tuba City, AZ.
Dr. Stewart said the Indian Health Service is a great opportunity for a graduating resident who is interested in experiencing something totally new. “It's a very unique and varying practice. You will develop skills you wouldn't have the opportunity to develop anywhere else,” he said.
One of the other plusses is the very low cost of living in these areas. Many physicians, like Dr. Stewart, sign with the IHS with the idea of putting in a few years, and find that the work is so compelling and rewarding, the life experiences so diverse and fascinating, that they never leave. I encourage every emergency physician — graduating residents, those tired of fighting for billing in a fee-for-service group, any physician approaching burnout — to consider the VA and the IHS. Not only will you find a whole new world of gratifying service, you just may find there's a great deal in it for you.
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