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Career Source: Front Money: Where Does It Ends?

Katz, Barbara

doi: 10.1097/01.EEM.0000413886.35422.d4
Career Source


An employer in Iowa is offering a first-year package worth just shy of $350,000 — before benefits. But there's more, a lot more. Employers hoping to attract residency trained emergency physicians are also offering front money: a $25,000 sign-on bonus, a $10,000 relocation bonus, $100,000 in loan forgiveness (for a multiple-year contract), and $20,000 in monthly stipends once the physician signs on.

That's a guaranteed $155,000 before the physician even steps foot in the ED! Now this is not a West Texas wasteland with tumbleweed blowing down unpaved streets and rattlesnake walls around the homesteads. It's not a bad neighborhood in an inner city, and it's not a remote swamp deep in the Everglades. It is a lovely area with wonderful schools, a terrific small-city lifestyle, a strong economy, and a very high-tech medical environment. The area has countless festivals, professional sports, riverfront recreation areas, and cultural and historical attractions. The hospital itself has won awards for patient care excellence with exceptional patient satisfaction scores.

So why do they have to lay out nearly $150,000 in front money to attract emergency physicians? The answer is pretty much because everyone else is doing it — or at least all the employers not in San Diego, Charleston, Seattle, Boston, San Francisco, and Colorado.

It's an interesting dichotomy. Emergency medicine is definitely experiencing a shortage of physicians. Back in the late 90s and up until about 2006, there were not enough good jobs for emergency physicians. Competition on top positions was fierce, but employers didn't expect physicians to pay them front money. Now the tables have turned — dramatically so.

I wrote a column at this time last year about graduating residents' poor interview behavior; they were walking into interviews and asking about sign-on bonuses before even taking a seat. That behavior has escalated. Unfortunately, I have trouble finding a great deal of fault with graduating residents coming out of their programs with enormous loan debt and young families wanting to get their piece of the pie. How long can this go on, and at what point does it harm the specialty?

The large national groups, whether corporate entities or physician owned and run, have the financial capability to put these front packages out there, but at some point, if they have to do it for all of their sites, it becomes prohibitively expensive. What happens when a physician going for a job in a popular lifestyle location begins comparing notes with a colleague interviewing for the same group in a less desirable location, with the latter getting a huge front package while the former is barely getting a relocation bonus? Certainly the group can cite the difficulties of recruiting in less popular areas, but can they expect any candidate to accept that and not play the equity card? If they are offering jobs to physicians with the same credentials and work history (and that is often the case with graduating residents), how do they justify offering one but not the other a huge package?

So how do rural employers in the most-difficult-to-recruit areas compete with the employers throwing everything but the kitchen sink into the mix? Obviously, if you are an employer in a highly desirable lifestyle area, most of this is moot. Emergency physicians understand that you pay for the privilege of working in Colorado, for instance, with lower incomes.

Many employers and physicians are concerned that all this front money is not only breaking the bank, but also not necessarily buying the physician for more than a year, which puts them in the position of having to fork out the front money again. Most of these contract deals come with a one-year employment contract. Though some employers hold some of the sign-on bonus for re-signing, most do not.

The truth is that physician retention is not the focus of most employers, and it should be. If the practice environment and basic income status is strong, the need to recruit new physicians becomes less of an issue. Emergency physicians are the most mobile of all the specialties. It used to be that the average emergency physician took a new job every five to six years. But the depressed real estate market and economic uncertainty has put a major crimp in that trend. Physician families are often less open to relocation, especially when it means removing young kids from their schools and selling a house. It makes more sense for employers to put the front money into sporadic retention bonuses over three to five years. They could also put some effort into creating more satisfactory work environments. How about sinking some bucks into EMR and documentation systems? Why not think outside the box a bit and create department team bonding events? People who really enjoy working together accomplish more and are less likely to leave, especially if they play together.

The market for emergency physicians is going to remain as hot as a pistol for the foreseeable future. If employers keep throwing front money at physicians, retention just becomes more problematic. I would really like to hear some ideas from all sides of this situation on what would be a reasonable sign-on incentive, ideas for retention, and how we can make the entire job market more equitable for all involved. Emergency medicine is a small specialty compared with others, and every person involved in it is susceptible to major problems should the whole shooting match go down in flames.

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Ms. Katz is the president of the Katz Company, an emergency medicine consulting firm dedicated to providing expert physician recruitment services and training emergency medicine residents in effective job searching.

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