Employment Pitfalls

That’s how they’ll get you!

As a board-certified Ob/Gyn, I have been in some truly horrific employment situations. So have a really shocking number of my friends and acquaintances. I have heard even worse situations from people I vaguely know via the Internet. There are so many traps to fall into, so many ways they’ll get you. This article simply lays out as many of them as I can think of right now, so that you may learn from my and others’ experiences and avoid these snares yourself. Good luck.

The Ever-Expanding Free Call Coverage

This has happened to me.  So, let’s say you join a lovely practice. The call is 1:6, and you have a reasonable number of patients. 1:6 call at the volume you have is a busy but fulfilling life. Then, one of your partners quits. Now, your work is really too busy to be sustainable. However, administration tells you they are working on hiring. It’s such a tough job market.

Sadly, another one of your partners quits. Now, you are taking 1:4 call and having to take care of all your other two partners’ patients in the office as well. This is insane! In fact, it is grossly unsafe. You never see your family. You are tired all the time. You are having panic attacks and crying at work. Surely, administration will hire locums or do something to help you, right? Wrong. You signed a contract that states you will take “an equal share of call” for your group. You are taking 2.5 extra days of call per month, or 60 hours of extra call for month – performing all manner of unpaid labor that is not reimbursable via extra RVUs (triage calls, post-op problems, ED and triage visits that reimburse peanuts, etc.)

From an administrative point of view, this is great! They don’t have to pay overhead expenses for another physician, and you are generating so much revenue for them! Sure, they have a position open – and they hope it will get filled – but they are not making any extraordinary efforts to fill it. And locums coverage is simply too expensive. Your contract requires you to work an inhuman amount of call given the volume of your practice, reasonable for 6 physicians but not 4. Too bad for you!

How can you avoid this? Add a clause in your contract that requires additional call pay if the call coverage drops below a certain amount and the requirement that your employer contract locums coverage if the call coverage drops below a certain amount.

The Extremely Geographically Expansive Non-Compete

This happened to someone I knew. Let’s say you’re underpaid at your job. You have found a new, better job in a city halfway across the state. This is perfect, because your noncompete will not allow you to take a new job within 20 miles of your old job for 18 months after you leave your job. No problem – your patients love you, but they’re certainly not going to drive 2 hours just to see you. Nobody could argue that you are a “competitor” or stealing patients from your old job.

Surprise! Your noncompete clause stipulates that you can’t practice within 20 miles of any facility of your old job! It turns out that your hospital has an outreach clinic in your new city! Essentially, your university employer has outreach clinics throughout your state. Therefore, the entire state is off limts to you. If you want to leave your job, you will have to move to a new state.

How can you avoid this? Make sure your noncompete only applies to locations you spend at least 50% of your time at or something like that.

Buying into a Failing Private Practice

This happened to me. Once upon a time, I was hired straight out of residency by a lovely private practice. I signed a contract that had a two-year partnership track. That is, after two years, if I like the practice and they like me, I would be allowed to purchase my share of the practice and become an owner! This would give me an equal share of the practice’s profits, which were promised to be larger than my salary.

After two years, I was happy in my job and liked my partners. However, I was worried about the practice’s financial status. It had been around for a long time, but the world was changing. (See future article, “The Demise of Private Practice.”) One of our most productive partners had quit to go be a hospitalist in Colorado. Two others were quite senior. There was squabbling about money among the partners, and it didn’t seem like we were going to be able to hire a new Ob/Gyn any time soon.

My partner proudly offered me the opportunity to buy in. I thought about it. I was nervous about making that financial commitment. I asked if I could maybe just stay on as an employee of the practice, maybe with a raise? I liked my job and my partners, and I was happy, but I was nervous about becoming a part owner of the business.

My partner frowned. She said, “Usually, at this point, either a doctor buys in or leaves.” She did not look happy.

I didn’t want to be let go from the job. I also didn’t want to disappoint her. Against my better judgment, I signed a loan for $120,000, which is what the practice’s accountant valued my stake of the practice at.

Let me say that at this point, I still had student loans, a mortgage, and three children under three.

Then about a month later, she announced that she, too, was leaving the practice.

This was the practice’s death knell. I panicked. I cried. I worried that I had ruined my family’s future. I figured I could kiss that $120,000 goodbye and just add it to the pile of debt I carried already.

My partners were truly good and fair people. Because of my distress and the abrupt change in the practice’s status, they agreed to refund my $120,000 and turn me back into an employee at my previous salary.

Do I feel bad about this? Not really – the partners made quite a bit of money off my very productive and hard-working self while I was an employee, and they all made plenty of money during what was, if not the golden age of medicine, a time when private practice was still quite profitable.

How can you avoid this? I mean, honestly, just don’t be an idiot like me and buy into a failing private practice so as not to offend your partners.

You Never Get To Be Partner

This happened to someone I knew. Let’s say you join a private practice right out of residency – say in a very desirable city, where it is actually fairly easy to hire an Ob/Gyn. The salary is low, but there is a promise of becoming a partner – and partnership is lucrative! There is no defined partnership track, but you are told that typically new associates are offered partnership in about 3 years if all is going well.

Then, let’s say that as the years go by, none of the junior associates seem to be offered partnership. The senior partners start dropping OB, dropping call, and generally cutting back.  You are working harder and harder for them, and making a modest bonus, but that partnership offer still is not forthcoming.

Eight years later, you are still not a partner. You quit.

How can you avoid this? I don’t know, hire a contract lawyer.

The Men Take the Ladies’ Revenue

This happened to my former partners, which is why they started their own all-female practice over 20 years ago. This is an insidious one. Many practices pool OB revenue. Seems fair, right? After all, we all take equal call. We can’t control which patients come in on call! Splitting the global OB fee is so complicated. It’s easier to keep our own RVUs from gyn office visits and surgeries, and we’ll put all the OB revenue into a pool and split it equally. Fair and easy.

Soon enough, though, the women in the group notice something happening. Through no fault of the male partners, the patients simply feel more comfortable seeing a female OB. They are especially nervous about delivering with a man, so when they need to be induced, they ask who is on call and the dates with female OBs happen to work better. The female OBs notice their schedules are chock-a-block full of OB appointments, and it’s hard to fit in those annuals and gyn consults. Meanwhile, they are constantly at the hospital supervising inductions when they are on call. The male partners are booking hysterectomies left, right, and center, chilling out while on call, and laughing all the way to the bank.

 How can you avoid this? If you pool OB revenue, make sure there is a mechanism to make sure OB patient care is also divvied up equally.

The Senior Partners Who Don’t Take Call

This is a tale as old as time. There’s nothing wrong with cutting back. We all know it’s harder to recover from a long night on call as we get older. Let’s say you are a young, eager Ob/Gyn. You join a practice at 1:7 call. Your senior partner turns 50, or 55, or 60 and announces they are no longer taking call. That’s a young person’s game. You wish to be compassionate, and you yourself would like to cut back some day, so you agree. Then another partner does the same. Now you are taking 1:5 call, but there is not enough volume to hire a new doctor, since the senior partners are still seeing a full load of patients in the office and even performing C-sections! They are billing plenty of RVUs from these office visits and daytime deliveries, so you are not seeing much of a bump in your pay, despite spending many more hours at the hospital.

How can you avoid this? Make sure financial reimbursement for taking your senior partners’ unwanted call is in your contract. You are unlikely to ever get a similar sweetheart deal to any you give to your senior partners.

New Bishop, New Rules

This happened to me. Let’s say you take a lovely job with privileges at a Catholic hospital. After all, Catholic hospitals make up a good chunk of U.S. hospitals, and many Catholic systems have sneaky names like “Dignity” and “PeaceHealth” that don’t sound religious at all. Let’s say you are wary of Catholic birth control restrictions, because you believe in a patient’s right to have birth control if she wants, but the person who hires you tells you not to worry – the hospital has “workarounds.” For example, the OR where C-sections are performed is a different nonprofit corporation on paper, so it’s not owned by the Catholic hospitals, and tubal ligations can be performed there! It’s even jokingly called the “sin room,” since birth control is so bad and wrong. You take the job, happily sterilizing your patients as they desire, and nobody bothers you.

Until a new bishop is installed in your local Catholic diocese. And he, personally, is opposed to workarounds. And he sends his enforcers to your hospital to sniff out and shut down the sin room. Because he, just one man with no training in medicine, has the arbitrary power to do that, because that is how the Catholic church actually works, in real life, in the year 2024. (This happened in 2018 but is still in effect.) Now you are no longer allowed to perform tubal sterilizations, and you are told to your face, in a big meeting, that performing tubal ligations is the worst sin a person can perform. Yes, you, the Ob/Gyn, saving your patients’ lives on a daily basis, are a bad, bad person and must be stopped in all this sinfulness.

How can you avoid this? Never, ever work for those institutional Catholic assholes.

Now Your Partners are Family Medicine Only

This happened to somebody I know. Let’s say you take a job in a small town. A low-resource Level 1 hospital is very different from where you trained, but you are up for the challenge, especially since you will have two senior partners to guide you. However, soon after you start, both your partners announce they are quitting. Because Ob/Gyns are so hard to come by these days, your hospital administration decides to hire family medicine doctors who did an FM-OB fellowship instead.

These doctors are lovely humans, and they can even perform uncomplicated C-sections, but they don’t do any surgery, and they’re not terribly confident in non-standard obstetric situations. It sure is a tough spot to be in to essentially be on primary or backup call 24/7/365.

Unfortunately, you don’t get any additional compensation for this new role of the only Ob/Gyn in town, since your contract said you would be on call 1:3, and you are technically on call 1:3.

How can you avoid this? Make sure your contract states your call partners will be other Ob/Gyns if that is your understanding of your job.

The Venture Capital Buyout

I only know about this from Internet stories. I don’t totally understand how this works. Your practice is doing well. Your senior partners, who are about to retire, decide to sell the practice to a venture capital firm. They get a million dollars each and retire. You have to see patients every 5 minutes all day long and don’t get bathroom breaks. You can’t get out of your contract because it is diabolical.

How can you avoid this? I don’t know, maybe this is just where we are at in late stage capitalism and we are all doomed.

Well, that’s all I have for now. I’m sure I’ll think of more ways they get you and write a nice, cheerful Part 2 to this article.

Karla Solheim, MD, FACOG