Survivor Saturday - 1st year post-training

Someday, believe it or not, you will "Be Done." Oh, glorious day!

Alexandra recently asked us

I'm very curious still about the transition from residency to practice. How did your husbands get their jobs, what benefits have you seen offered at different places (ie. loan repayment, moving stipend?), and what kind of reality check did you get when you saw that first paycheck? Also, how much have time constraints changed now that they are practicing vs med school and residency. I think a lot of us need to hear about the future sometimes to keep us motivated for the payoff. And I don't mean the money, I really mean how has family life improved/gotten worse.

No one told me what to expect when we Were Done, and some of it took me by surprise. I can only speak from my experience, and I know that the logistics of your own experience will vary based on the kind of practice your husband joins (private vs. academic – i.e., a staff position at a teaching hospital, usually involving research) and the practice itself (big group vs. small group, metro area vs. rural area), not to mention the specialty itself. My husband joined a private practice with two other specialists in his same field, and we live in a large metroplex.

The best way for your husband to find a job is by word-of-mouth through the department where he is training and his specialty’s national academy. As a rule of thumb, if a practice has to resort to a headhunter to fill a position, that usually means they have had a hard time finding someone, and that may not be the place you want to be. During your husband’s final year of training, he should have a job secured by the late fall/early spring. The main reason for this timing is the obscene amount of paperwork involved in starting his practice. He will need to be approved for every insurance plan accepted by his practice (called “credentialing”), and if he is going to practice in a city with more than one hospital, he will need to apply for hospital privileges at each one. If you are moving to a different state, he will need to study for and take a state licensing exam. All of this paperwork takes months to complete and receive approval, and without it, he can’t start seeing patients. A good office manager or department secretary will be vital in this process. (Send her flowers.)

As far as things like loan repayment and moving stipends, that will depend on the practice. Generally, larger established practices will probably offer more of these things than smaller ones. We did get a moving stipend (oh, blessed joy! I didn’t have to pack a single thing!), and he was also offered a series of “signing bonuses” for having met deadlines on the aforementioned paperwork. That was so exciting. I went to Talbot’s and bought something that wasn’t on the clearance rack just because I could (I don’t think I’ve done that since then, but it sure was a rush!). My one request, though, was new bedroom furniture. We slept on a metal frame with a mattress & boxspring and put our clothes in hand-me-down dressers for 8 years, so our first big purchase with the post-training paycheck was a bed and dresser from Ethan Allen. However, we saved most of the bonus money so he could take some time off between his graduation and his first day of work - the bonuses covered our living expenses for almost two months. All of those bonuses and stipends just added to his buy-in amount (explained below), so it came out of his pocket in the end, but it was still really nice.

As far as Paycheck Reality Check, the pay increase is really great, but we don't really notice that big of a difference month-to-month because we have a bigger house with a bigger mortgage and bigger bills. Loan repayments will take a big chunk of that paycheck, too. Our kids are older now and involved in more sports and activities (which all cost money), and they would not have been able to do all that they do during training. We definitely have more freedom to do more fun things that we couldn't do during training, but we still have to be careful and frugal.

Most groups will offer a period (usually about a year or so) of a “try-it-out” time with a set salary (yes, probably double or triple the amount of his last year of training, minus an unbelievable amount for taxes and malpractice insurance). During that time, he can make sure the practice is a good fit for him. The reality is that about ½ to 2/3 of new practicing doctors changes practices within 5 years. (Both my husband’s partners came from a different practice before starting their own, so I told him that they have taken care of the 2/3 and we can stay right where we are, thankyouverymuch). But the relationship your husband will have with the docs in his practice will be very much like a marriage, and he needs to make sure that it works for everyone.

After the trial period, he may be offered a partnership. This will involve a very expensive buy-in where he literally buys a fraction of the practice’s assets and charts. He could either take out yet another loan and complete his buy-in immediately, or (as we did) take an amount out of his paycheck every month until it is paid off, and then he will be a full partner with profit-sharing benefits.

The biggest shocker, though, was the time and frustration involved in building his practice. It was a solid year before he had full clinic and surgery schedules. He spent a lot of time shaking hands with primary care providers and other referring physicians just to get his name out there. He was pretty frustrated for a while when it wasn’t moving along as fast as he would have liked it to, so my job was to keep encouraging him and being as emotionally supportive as I could be. I know we all complain a lot about how hard it is on us when our husbands are working so much and are so busy and so tired, but when he doesn’t work as hard because he’s only seeing 8 patients a day – well, that also takes its toll.

The other big adjustment for him was learning how to run a small business. All of the payroll, staffing, billing, collecting, insurance, and other overhead cost issues are someone else’s responsibility while he’s in residency, but once he’s in private practice, and especially once he’s a full partner, he has an ongoing education in business. It adds a whole new level of stress on him, and again, requires an extra measure of his wife’s support. Every practice will be different – but I’m speaking from our own experience.

As far as time – take heart, ladies, because it DOES get better. It’s still a lot of hours and stress, but I’ve found that now he has more control over his schedule. He can take as much vacation time as he’d like (but taking vacation means not seeing patients + paying overhead = losing money. Getting him to take time off during the first couple of years was really hard, but he’s better about it now). He’s able to schedule time off or make sure that he’s not on-call for important family events. He joined a practice with two other guys who also have young kids, and as a group, they decided that they are going to work hard and serve their patients, but they are also going to go home and eat dinner with their families, coach Little League, etc. There are still nights when he doesn’t get home until 7:00 or has to go into the hospital at 1 a.m. or is on his way home when he gets called in – but I think those occasions have been fewer now than they were during training.

I apologize for rambling on for so long! But I wish someone had told me all of these things before he finished training, so I hope this was helpful for you and gave you some kind of idea about what to expect.

Jennifer