Every year, Strategic Radiology (SR) hosts a Virtual First Year in Practice Happy Hour for residents and fellows held in the fall. An annual highlight, the virtual event features a panel of early-career radiologists from SR groups responding to questions submitted by the radiology resident and fellow community.

Last year's event was moderated by Cuong Nguyen, MD, a neurointerventional radiologist who leads recruiting for Mecklenburg Radiology Associates, a 55-radiologist practice based in Charlotte, NC. The panel included four radiologists completing their first and second years with four private practices, all SR members, a coalition of 38 radiology practices. Dr. Nguyen was joined by:

• Karen Grajewski, MD, Body Imaging & Nuclear Medicine, Affiliated Imaging Associates—Huron Valley Radiology Division, Ann Arbor, MI (60 radiologists);

• Alan Harrell, MD, Women's Imaging, Mecklenburg Radiology Associates, Charlotte, NC (55 radiologists);

• Christopher Rouse, MD, Neuroradiology, Southern Radiology Consultants (22 radiologists), Baton Rouge, LA; and

• Barry Rush, MD, Body Imaging, Quantum Radiology (90 radiologists), Atlanta, GA.

Part I of the article focused on how to prepare for real-world radiology; how to avoid common mistakes residents and fellows make; and a hot tip for finding your blind spot; Part II continues with insider tips on how to navigate the interview process, avoid rookie mistakes, achieve work-life balance, and assess practice culture.

Things I Wish I Knew

In retrospect, Dr. Grajewski wishes she had known that all private practices are not structured in the same way. She was surprised to discover that all groups are modeled differently, based on daily responsibilities, methodologies for calculating compensation, and back-office personnel and duties. "Every group is completely different, so you need to figure out what matters to you," she noted. "Is it important to you to have ancillary staff that help you contact clinicians? Is it important to you to know what you're getting paid every month, and then maybe have a bonus pay out quarterly, or are you flexible with how your financials are handled? Do you like moving around to different locations in a given week, or are you a homing pigeon who wants to go to the same hospital day in, day out and just settling and nest there? These are things that you need to be thinking about when you're going out on your interviews."

Dr. Harrell wanted attendees to understand that just as there are many different types of private practices, there are many ways of finding and securing a position with a private practice. At one time, residents and fellows began their job search shortly before they came to the end of training, but now recruiting is year-round and many residents are beginning the process earlier in training. "It's the Wild West," reports Dr. Harrell. "There will be a job at one practice one week, and it's gone the next week. Some places will still have a job after one month, and they'll have it for years; there are other places where you'll never hear of jobs, but people are still being hired, because it's who you know. You have to pace yourself and know that you are on your own timeline, and that's okay. If you're early in the process, tell people that because if they're in a rush to hire, they can let you know. Just be ready to put your best foot forward everywhere."

Dr. Nguyen cautioned against being pressured into taking an offer. "If a practice gives you two days to sign the contract, I would say run," he advised. "Well respected practices would not pressure people into signing a contract. Sometimes we have deadlines from other candidates, and we will be pretty forthcoming about that, but we don't arbitrarily say you have a week to sign a contract. We understand. You have to evaluate your options." 

What Is and Is Not Negotiable

When it comes to private practice employment contracts, some things are more negotiable than others. For instance, Dr. Grajewski reports that a friend negotiated for a longer track to partnership in exchange for a four-day work week. Some practices cover a dozen or more hospital sites, some of which might entail an exceptionally long commute. "If there's something you want from the practice, just ask them to put that into the contract," she advised. "Maybe they can't, but if it's important to you, ask. If it's not in the contract, it might not be honored."

Dr. Crouse also urged residents to feel comfortable bringing up issues that are important to them. "If it's a reasonable practice with reasonable people, they're going to hear you and acknowledge that," he said. "If they can't accommodate your request, they'll let you know, and no one is going to hold a grudge. For all of you right now, it is important to just keep in mind that the current job market is really good for you."

Dr. Grajewski also advised trainees to familiarize themselves with how malpractice insurance works and what tail coverage is. "If your group sells out, will they still pay your tail?" she posited. "I've anecdotally heard of that happening to people whose groups were bought out by private equity; that basically nullified the tail coverage agreement."

She added: "Just keep in mind that a lot of healthy private practices will not change much of the verbiage in their contracts. That isn't necessarily a red flag for you unless there's something in there that's very concerning to you. One thing that might be of concern is a non-compete. I will hope for all of you that your 1st job is your last, that you're happy, and it works out. Unfortunately, in the real world, that's not always the case." A rigid non-compete clause prevented a friend of Dr. Grajewski's from securing a new job in the geographic area that she had chosen to live.

On the other hand, salary and vacation time are unlikely to be negotiable in private practice. "At a healthy private radiology practice, there is not going to be a lot of variability on how you're compensated, or how your time off is doled out," Dr. Grajewski said. "A healthy practice will be very egalitarian, so, you don't necessarily have a lot of opportunities to negotiate your vacation time, or your salary."

Lawyer Up or Not?

Not all panelists opted to hire a lawyer to look at their contract, but most advised having someone who is savvy in legal matters review the document. Dr. Grajewski suggested having a second pair of eyes on the contract, someone outside your family or friend group. "It doesn't necessarily need to be a formally hired lawyer, it could be somebody with a business background or a legal background," she advised. "That might just help you catch something. And again, the things you should look for in the contract are tail coverage, non-compete clauses, malpractice, and one other thing I forgot to mention: If you will be responsible for any mid-levels or trainees, what sort of liability do you have for the actions of others?"

One of the panelists hired a lawyer to represent him throughout the negotiation process. "It was a waste of money," Dr. Rush said. "I read somewhere that in the interview process, we have to present our best selves and then play hardball once we get an offer. While the first part may be true, I'm not entirely sure the second part is. You really just want fairness, you want to make sure that you're treated fairly."

"These are great points," Dr. Nguyen said. "I chuckle a little bit because I remember when I got my first contract. The president of the group said, 'Cuong, what I'm going to do is send you this contract. Have a lawyer look at it, and they're going to suggest all of these changes, and we're going to make none of them.'"

"I do think that it's important for you to have an attorney specialized in physician employment agreements to look at your contract" he continued. "I got a lawyer to look at mine, and she raised multiple issues, including tail coverage, non-compete, malpractice, and the president said: 'All good points. This is the same contract that everybody signed for the past 30 years, so we're not going to change it for you.' I signed the same contract too."

Whether or not a group's contract is negotiable, Dr. Nguyen urged residents and fellows to consult a lawyer to fully understand the contract they are evaluating.

"Although you can negotiate with certain practices, a lot of established practices won't change the terms of the contract; the contract is written to protect the practice, not the individual radiologist," he said. "That's just how it is. But it's important to understand what you sign up for."

Practice Culture

Work-life balance is a practice attribute that has grown in importance, and that is an area where your instincts and choices will be more helpful than a lawyer. "We are fortunate to have a little bit more vacation time than most other specialties, which is good," Dr. Rush noted. "But a practice also needs to set boundaries so that you won't be called outside work hours unless there is a significant emergency—or you've given the GI doc your cell number. Having boundaries is important because you need to have your personal time."

Dr. Crouse agreed that having a clear division between work and home lives is important, along with clear communication of work expectations.  "Most practices are going to give you as much time off as they can, at least that's how my group operates," he said. "We give as much vacation as we can squeeze out of the schedule without causing overwork while you're at work, and I think that's the balance. For everyone, it's a little different. I know a couple of other groups that work maybe a little bit more intensely than I do during the day but potentially get more weeks off."

Dr. Harrell suggested paying close attention to the people to assess the practice culture and find a practice fit. "When you're on your interview, ask yourself if these are the kind of people you can strike to deal with," he suggested. "If these are the people that you can have an easy, normal chat with, they are your people. And that's why the people are so important to realizing what the culture's like and if you're going to fit into that culture."

Dr. Crouse agreed that the people—and their values—make the place. "As long as you're in a group that has like-minded people and the decisions are made together, everyone's going to be working towards achieving work-life balance," he said. "We've all got families and kids, not everybody, but everyone has other things outside of work that they're trying to do. Hopefully if you join a group of like-minded people, you'll work towards those goals together."

So, urges Dr. Grajewski, before you start interviewing, spend time thinking about what is important to you. Are you an early bird or a night owl? How much commuting time are you comfortable with? How many weekends are you willing to work in a year? "What initially seems doable can get old really fast when you are considering things like a drive that is more than 45 minutes or you have to get up at 5 AM to get somewhere by 6 AM," she said.

One question Dr. Rush would ask when interviewing is this: When someone asks or sends out a group email asking to switch a shift because they have an important family event, how frequently are they not accommodated? "I have seen a lot of emails from people needing to switch a shift in the year that I've been here, and there hasn't been one instance where somebody hasn't been accommodated" he said. "That makes you feel like you have a lot of people who are there to support you, your family, and your needs, and it makes me feel good."

Dr. Nguyen concurred: "You can talk about all of the other factors—compensation, vacation, work-life balance—and at the end of the day, the people that you work with are the most important aspect of the job. If you don't enjoy going to work to see the people at work, it's not worth it. And that's one thing I would stress: Make sure that the group you're joining consists of people you want to spend a lot of time in a room with, because I spend more time with these guys and gals than my family."

Part 1 of this article appeared in the October 2023 issue of Hub, a quarterly newsletter published by Strategic Radiology.   If you are a resident or fellow and interested in the private practice setting, upload your CV here and we will distribute to all 38 independently owned private practices with membership in Strategic Radiology.