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Can I rectify this mistake: Not negotiating shrewdly?

Home Personal Finance and Budgeting Can I rectify this mistake: Not negotiating shrewdly?

  • Avatar GPGP 
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    Q-school, it is exceedingly clear to me that we have never practiced at the same institution! I wish we had that level of thought and preparation.

    #161509 Reply
    Liked by Vagabond MD
    Avatar jacoavlu 
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    contrarian option: take ownership, be a leader, maximize use of available resources, don’t ask for anything unless you absolutely need it, build the best stroke program you can possibly build

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #161516 Reply
    Avatar ChristopherMD20 
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    I have a lot of thoughts on this, but it’s truly a challenge to imagine the culture and background of any system. For us, there would have to be a significant reason for an offer to be made to a new graduate to be a medical director.   I can’t even imagine a situation where this would occur.  Most medical directors supervise different specialties anyways.  The medical director is responsible for much more higher level functions-strategic medical decisions, high level disciplinary activities, negotiation of contracts, internal negotiations of responsibilities across various specialties, development of institutes and centers of excellence, etc etc.  even associate and assistant medical directors would never be offered to new graduates.   Maybe after two years experience if someone were the only one in a specialty, they might be offered a service line lead. They then are enrolled in a leadership program for one year.  They have a project they develop.  They train you how to handle difficult situations and have so called crucial conversations.   Write up business proposals.  Take accounting class so you can participate in meetings with administrative dyads.  Etc etc if your position has you doing those things, i would say quit.  Your first two years should imo be spent gaining clinical excellence.  No matter how good your training you still get better in your first few years.

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    Wow thank you for such a thoughtful response.

    I am a bit handcuffed. My main goal is to affect change to the practice of stroke care in our hospital system. I feel that, in order to be taken seriously, I do need to title to get other departments to take my recommendations, algorithms and care pathways seriously. I am a young attending and a lot of nurses and other doctors keep mistaking me for a student. I do not even have an office at our hospital, I carry around my tools and a laptop in a bag while running around the hospital. I am not sure I am willing to “sit on the sideline” when I feel there are a lot of things that need to change in order for the care to be optimized. Essentially, I have been attempting to do the job since I started anyhow. I have gone to the meeting and met with other departments and given some seminars/lectures to different medicine and nursing groups. The previous director did not actually participate in any of the leadership responsibilities. These responsibilities will ultimately be my problem whether or not I accept the position. I am a major “yes man” and “people pleaser.”

    The first few years after you graduate are easy in some way—you don’t have ‘that’ many patients yet, you have a lot of energy, you are amazed at how much money you are making.   The next few years you have kids, you don’t get any sleep even when you are not on call, and you start taking vacations and buying a doctor house.   You have to read more to stay current.  You sit on more and more committees.  You have to learn how to restrain your innate desire to be helpful and learn to just listen to people complain.  You have to learn to have a few knives in the back.

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    If things get busier than they are right now, I will need to figure out a way to divert some workflow. In my first two months as an attending, I have billed for ~5-10% more wRVUs than any of the other people in my specialty in our system. I could see more patients, but that would negatively impact their care. Also, I am not productivity based, I just get a salary. I do not think I am going to reach the productivity bonuses.

     

     

    #161521 Reply
    White.Beard.Doc White.Beard.Doc 
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    If this is medical director of the stroke program in a small community hospital, then there may or may not be compensation that goes along with the position.  The stroke neurologist would play this role typically, and there may be a stipend from the hospital, or not.  The complexity of this position typically depends on the size of the hospital and the services provided.

    So, this position might qualify you for a stipend, but there also may be value to you early in your career to gain leadership experience and build your resume.  It isn’t just about the compensation, but that is a part of it.  I have seen this position be a half time position at a major tertiary teaching institution, and I have also seen it be a couple of hours a month with the majority of the responsibilities covered by a full time specialist RN who runs the stroke program and does the heavy lifting with just a bit of support from the MD.

    So, in answer to your original question, “It depends.”  The details matter.  My advice, be professional, be supportive, and don’t be shy to ask politely if a stipend goes along with the extra responsibility.  And if this position prevents you from fulfilling other more important responsibilities, don’t be shy about sharing that either, and with some notice it is reasonable to step down from the position if it is not working for you.

    #161527 Reply
    Avatar Tim 
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    Can I get an AMEN for q-school !
    Pure wisdom and concrete guidance of what steps you need to accomplish if you choose to assume duties of medical director.
    Brings up an interesting question. Do you really wish to take that path in your career?

    #161529 Reply
    q-school q-school 
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    I have a lot of thoughts on this, but it’s truly a challenge to imagine the culture and background of any system. For us, there would have to be a significant reason for an offer to be made to a new graduate to be a medical director.   I can’t even imagine a situation where this would occur.  Most medical directors supervise different specialties anyways.  The medical director is responsible for much more higher level functions-strategic medical decisions, high level disciplinary activities, negotiation of contracts, internal negotiations of responsibilities across various specialties, development of institutes and centers of excellence, etc etc.  even associate and assistant medical directors would never be offered to new graduates.   Maybe after two years experience if someone were the only one in a specialty, they might be offered a service line lead. They then are enrolled in a leadership program for one year.  They have a project they develop.  They train you how to handle difficult situations and have so called crucial conversations.   Write up business proposals.  Take accounting class so you can participate in meetings with administrative dyads.  Etc etc if your position has you doing those things, i would say quit.  Your first two years should imo be spent gaining clinical excellence.  No matter how good your training you still get better in your first few years. 

    Click to expand…

    Wow thank you for such a thoughtful response.

    I am a bit handcuffed. My main goal is to affect change to the practice of stroke care in our hospital system. I feel that, in order to be taken seriously, I do need to title to get other departments to take my recommendations, algorithms and care pathways seriously. I am a young attending and a lot of nurses and other doctors keep mistaking me for a student. I do not even have an office at our hospital, I carry around my tools and a laptop in a bag while running around the hospital. I am not sure I am willing to “sit on the sideline” when I feel there are a lot of things that need to change in order for the care to be optimized. Essentially, I have been attempting to do the job since I started anyhow. I have gone to the meeting and met with other departments and given some seminars/lectures to different medicine and nursing groups. The previous director did not actually participate in any of the leadership responsibilities. These responsibilities will ultimately be my problem whether or not I accept the position. I am a major “yes man” and “people pleaser.”

    The first few years after you graduate are easy in some way—you don’t have ‘that’ many patients yet, you have a lot of energy, you are amazed at how much money you are making.   The next few years you have kids, you don’t get any sleep even when you are not on call, and you start taking vacations and buying a doctor house.   You have to read more to stay current.  You sit on more and more committees.  You have to learn how to restrain your innate desire to be helpful and learn to just listen to people complain.  You have to learn to have a few knives in the back. 

    Click to expand…

    If things get busier than they are right now, I will need to figure out a way to divert some workflow. In my first two months as an attending, I have billed for ~5-10% more wRVUs than any of the other people in my specialty in our system. I could see more patients, but that would negatively impact their care. Also, I am not productivity based, I just get a salary. I do not think I am going to reach the productivity bonuses.

     

     

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    friend, the truest form leadership is influence without authority.  if you can convince without the title, you will know you are ready for the title.  🙂

    i had the opportunity several years ago to sit in on the neurology service meetings as the medical director of that area attempted to grow.  couple outside observations that may only be peculiar to our own institution but maybe be tiny bit instructive as you think about your options–

    it is clear that some of the senior neurologists have (had at the time) trouble with the idea of converting to cardiology model where they would be asked to come running.  i’m sure when they trained they double boarded IM and neurology and the vision was one hour of mystery solving followed by extensive testing and then an answer would be provided … eventually.  now they were asked to be available for hospital and ed stroke evaluations.   they had some trouble committing that they would.  the medical director was younger but mid career and had trouble telling grandfatherly looking doctor jones (rather than first name basis) forcefully that this is what the expectations were.

    the med director than had to interact and ask ED to change their triage protocols in a very busy ED.  Ditto for hospitalists.  The Medical Director has no ‘influence’ over these specialties, just had to convince them to convince their teams to follow the care pathways and algorithms and do things a little differently.

    At the same time, the neurology service was looking to specialize into epileptologists and stroke and those respective specialties were trying to focus on their particular areas.  answers for how to specialize and cover all the area 24/7 were needing to be developed with flexibility and yet commitment to specialization.  the idea was tossed around for dividing into inpatient and outpatient.  that was briefly attempted but the inpatient guys really were asked to shoulder a lot because they were there and the outpatient guys kept pleading with them–man i know you are the stroke guy, but could you just check on this patient because you are there etc etc

    The conversations took a round about way into vascular surgery and interventional radiology as the question of carotid interventions became available.  in the background lurked the always hungry interventional cardiologists.  like the sleeping lion, they are best avoided and if they smell the opportunity, they command a lot of attention administratively in the hospital.   again, influence without authority necessary because no one wants to be the backup singer, only getting to do work at night and on weekends.  plus sometimes even when issues are settled, they are not really settled.  only until someone can muster up another approach to getting their way.

    anyways maybe all these problems have been fixed by now in your place, or you guys do things differently.  i definitely could be off on some of the facts because my memory is fading every day.  point is– all this stuff takes time.  or other stuff takes time.  time is your most precious resource.   i would argue your point that people without a title are sitting on the sideline, but that’s a minor point.  i don’t think you are sitting on the sideline now.

    it’s a tremendous recognition and honor to be offered a medical directorship.

    PS-if you figure out a good way to divert work, please let me know.  that’s really the part that i’m personally curious about.  the nicer you are, the more people personally ask you to take care of husband/uncle/grandpa and a personal request is way harder to turn away than a random computer generated consult.

    best of luck always.

     

     

    #161563 Reply
    Dreamgiver Dreamgiver 
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    I have a lot of thoughts on this, but it’s truly a challenge to imagine the culture and background of any system.

    For us, there would have to be a significant reason for an offer to be made to a new graduate to be a medical director.   I can’t even imagine a situation where this would occur.  Most medical directors supervise different specialties anyways.  The medical director is responsible for much more higher level functions-strategic medical decisions, high level disciplinary activities, negotiation of contracts, internal negotiations of responsibilities across various specialties, development of institutes and centers of excellence, etc etc.  even associate and assistant medical directors would never be offered to new graduates.   Maybe after two years experience if someone were the only one in a specialty, they might be offered a service line lead.

    They then are enrolled in a leadership program for one year.  They have a project they develop.  They train you how to handle difficult situations and have so called crucial conversations.   Write up business proposals.  Take accounting class so you can participate in meetings with administrative dyads.  Etc etc

    if your position has you doing those things, i would say quit.  Your first two years should imo be spent gaining clinical excellence.  No matter how good your training you still get better in your first few years.  You need to build a solid reputation of excellence and availability.  you need to learn who your lifelines are—clinical and administrative.  You need to learn how to bill.  You need to learn what programs you want to develop, and which ones to say no to.   Go sit on some committees.  Chair some committees.  Learn how people lie to your face.  Learn to smile while someone is being ridiculous and wait them out.   See how effective people get things done.  Learn the players.

    i’m not thinking of the mistake that you are—not negotiating salary.  I’m worried they are using your name and reputation without you even being aware of it.  This policy was approved by Dr. x.   Dr. X, the medical director, has decided we can no longer afford to pay you overtime.   I have some minor concerns that trying this too early will hurt your long term career aspirations.  Capacity for human beings to be self absorbed is limitless.  Things that are inefficient for you probably are helpful to someone powerful.  You think you are helping clean up a problem, but you are pissing off the chair of another department.

    The first few years after you graduate are easy in some way—you don’t have ‘that’ many patients yet, you have a lot of energy, you are amazed at how much money you are making.   The next few years you have kids, you don’t get any sleep even when you are not on call, and you start taking vacations and buying a doctor house.   You have to read more to stay current.  You sit on more and more committees.  You have to learn how to restrain your innate desire to be helpful and learn to just listen to people complain.  You have to learn to have a few knives in the back.

    Of course i have no idea of the culture of your place.  But i would never put you in the situation that early on, certainly not without having a frank conversation about what responsibilities there are and an estimate of time requirements.   And if pay were appropriate, i would ensure you got the going rate.  But most of these jobs are not worth the pay.  Especially if you are the only one there, quit, and tell them you are flattered but you need another year to get settled.  Spend that year thinking and learning what the other medical directors do, how much time it takes, what the expectations are, and what the pay is.  Come back to them next year or whenever you think you are ready with a plan you design.  You control the narrative and the time.  Even when they screw you, it will have been a useful exercise.  :).  For me, pay is absolutely the last thing i think about with administrative duties.  There are many ways to get screwed worse than pay imo.

    good luck!

    congrats on being a successful attending!

     

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    “This is gold Jerry, gold!”

     

    And to answer your question about how to divert work…when someone asks I think of my kids’ faces if I am not around enough. That makes it easier for my mouth to pronounce the word NO.

    #161597 Reply
    Rogue Dad, M.D. Rogue Dad, M.D. 
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    Q-school definitely nailed it on the head.

    Learning to say “no” is hard, but I don’t think you were wrong to say “yes.”  However you do need to be given the resources needed to DO the job, whatever that entails.

    It sounds like you are doing all of this directorship work unofficially, so it’s time to make it official.

    My recommendation is to sit down and type of a one-page document with a short paragraph giving an overview of your goals for the program they want you to lead/develop.  Then provide a categorized list w/bullet points of the specific resources you need to do it and the compensation that is appropriate. Maybe you need resources to hire more physicians, NPs/PAs, secretaries, imaging equipment, whatever.  You definitely need somewhere to at least leave a bag; I’m sure they have an office they can give you.  Ask for an office with a window  — put it in the contract.  Ask for a yearly stipend of “$x” for the directorship that’s separate from all other compensation.  Ask for a written commitment from them they will provide resources to obtain who/what you need in a set time frame.

    I’m not great at saying no but I’m getting better.

    I’m trying to get our hospital to join a program to provide better care to children w/complex medical conditions.  They’ve agreed to join the program but it needs medical directorship.  I’m the one that’s pushed to get this program started, but also told them they won’t be able to get anyone to be medical director (me or anyone else) if they don’t provide salary support to offset clinical time.  Without going into too many details, it’s an initiative they want to get going, so simply not doing the program because they choose not to pay for a medical director at all is going to be problematic.  So supposedly they are working on the internal funding.

    The associate CMO of my hospital asked me to be a course instructor for a new quality improvement course the department/hospital is starting for physicians. I asked if there is salary support for time or compensation for doing this.  I was told no, so I told them that while I support the program concept (which I do) I declined.  Won’t surprise me if I’m the only invited person who declined.

    I told my division head my stance on these issues (didn’t really “ask” for support, just stated my position) and they have supported my stance.  The QI course is somewhat tangential for me anyway, so didn’t bother my boss that I wanted to say no.

    http://www.RogueDadMD.com

    An alt-brown look at medicine, money, faith, and family

    #161601 Reply
    Avatar Anne 
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    the truest form leadership is influence without authority

    Click to expand…

    This is maybe the best quote about leadership I have ever heard.  q-school you are my new leadership guru.

    My main goal is to affect change to the practice of stroke care in our hospital system. I feel that, in order to be taken seriously, I do need to title to get other departments to take my recommendations, algorithms and care pathways seriously. I am a young attending and a lot of nurses and other doctors keep mistaking me for a student. I do not even have an office at our hospital, I carry around my tools and a laptop in a bag while running around the hospital. I am not sure I am willing to “sit on the sideline” when I feel there are a lot of things that need to change in order for the care to be optimized.

    Click to expand…

    OP, if you do continue with the directorship, consider starting with an attitude of service (I know this may come off as preachy which is not my intent…just want to give some advice based on different “leadership” styles I have seen over the years, some of which are more “draggership” styles).  If you come on board as the NKOTB with new algorithms and care pathways, what you think you are saying is “here, I want to make stroke care better.  I come from an excellent training background and what I learned there could really help our patients.”  But what the people who have been working in the system hear is “you guys have been doing it wrong.  Here’s the right way.”  People don’t like change, especially when they’ve been doing something one way for a while, and they don’t like to hear or think that they may have been doing things in a less than optimal way for years.  That’s hard to swallow.  Consider starting with just getting a feel for the place and figuring out why things are done the way they are there before expecting someone to take your advice for change just based on your title.  If you can gain a reputation for being hardworking, knowledgable, and selfless (nobody is completely selfless, but you can show that the growth of the department–and the people in the dept–means more to you than your own personal needs) that will payoff down the road as people will *want* to make the changes you direct.  Start by listening and taking other people’s suggestions seriously–maybe even ask your team and the other departments “how can I make your job easier to allow you to better care for our patients”.  You might even get recommendations for change that are precisely in line with your own ideas, which if implemented can help the team to feel like they are improving the system through their own volition which will give you buy-in and trust for other ideas you have that might not have been as popular.  And you might get some ideas that you wouldn’t have thought of that might even be better than your own.

    #161753 Reply
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    Avatar ChristopherMD20 
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    alpha investing
    friend, the truest form leadership is influence without authority.  if you can convince without the title, you will know you are ready for the title.

    Click to expand…

    I am pretty sure this and everything else you have told me is the best professional advice I have ever gotten. Thank you for your thoughts and wisdom. I will try to respond to all these excellent points.

    #161807 Reply
    Avatar ChristopherMD20 
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    it is clear that some of the senior neurologists have (had at the time) trouble with the idea of converting to cardiology model where they would be asked to come running.

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    Yes, this is exactly the issue. I am the only neurologist that meets acute stroke alerts in the ER, at the door or in CT scan. The other neurologists care little about my thoughts on how things should run. They do seem to respect my knowledge (somewhat) because they often call me to help them with more complex stroke cases. The program I want to build includes eventual interventional neurologic procedures (clot retrieval).

    med director than had to interact and ask ED to change their triage protocols in a very busy ED.  Ditto for hospitalists.

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    Our ER and hospital groups are amazing and very receptive to the ideas being presented. It helps my cause that I am readily available.

    no one wants to be the backup singer

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    I am a neurologist, I have committed to being a back up singer to neurosurgeons and other procedural-based specialist. Haha- half joking…

     

    the nicer you are, the more people personally ask you to take care of husband/uncle/grandpa and a personal request is way harder to turn away than a random computer generated consult.

    Click to expand…

    I am innundated with special requests from coworkers’ family members. I practice mostly inpatient but I continue to have to add clinic slots because of all these requests. I am happy to help and I love what I do, but I want to protect against burnout long term. I still am a naive new attending who doesn’t know how to balance my time.

     

    Again THANK YOU so much!

    #161809 Reply
    Liked by hatton1, Zaphod
    Avatar Crockett’sRiver 
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    You are obviously a tremendous asset to your hospital and your colleagues.

    I think you hit the nail on the head in your original post when you said you are a “yes-man”.  Time to learn how to set reasonable boundaries. Start by asking for an office, for heaven’s sake – no one has offered you one up until now because you have made it work by running around with a laptop. If you ask, the answer will almost certainly be “of course!”. If the answer is anything different, keep asking, calmly.  Next, use the phone in your new office   🙂 to ask for a sit-down with whoever you report to so you can make a concrete plan for how you will have the resources you need to make your vision of stroke care in your hospital a reality.

    I say this as someone who has been totally conflict avoidant in the past and learned to do better.  If this makes you uncomfortable, remember that you aren’t asking because you are entitled/obnoxious/can’t cut it or whatever else you might be thinking.  You are asking because without boundaries and resources you can’t do the job you were hired to do.  Do not feel guilty, do not apologize.  You are doing right by your patients.

    Career and finance for PCPs at ADoctorsWorth.com

    #162442 Reply
    Avatar ticker 
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    Per The Google, average comp for stroke directorship: ~$35,000.  Average time: 300 hours/year.  I think you’re a little nuts if you are willing to do 5-6 extra weeks of work per year for no pay.  A stroke program would likely be a significant financial asset to your hospital if it is currently losing patients elsewhere.  I would ask for a meeting with the powers of the hospital, give a short presentation of the vision for the stroke program, explain how it will be a boon for the community and give lots of extra work to profitable service lines like neurosurgery, radiology, cardiology, etc., talk about the financials of the more streamlined care you’ll be able to provide (they love hearing about faster discharges) and higher volumes of stroke patients they’ll have, give an overview of all the terrible, onerous, backbreaking work it’s going to take the make this happen, and let them know you’d be excited to lead the charge for the $50,000 they’re going to pay you in year 1 (lots of extra work to get things going) and then $35,000/year thereafter.

    #162446 Reply
    Liked by Firefly
    Avatar BlueCollarMD 
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    You may have an easy way to have your cake and eat it too.

    The key is that you say you are on salary not production.  Embrace the medical director role, BUT make sure all your effort comes out of your clinical time.  Otherwise, you will be burning yourself out and resenting the lack of extra comp.  Keep track and make sure that you keep reminding them you can’t be in two places at once.  As your role and indispensability increases, you will have more leverage.  There is no question you need to fulfill this role.  For now, compensate yourself by restricting your clinical effort; later on you can ask for more comp.  If this doesn’t fly, then ask them how this is supposed to work?

     

    #162730 Reply
    Avatar sunshine 
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    Wow this thread is amazing.

    #162756 Reply

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