A Framework for Finding Your Ideal First Job

I’ve recently had the pleasure of connecting with several readers approaching the end of training and looking for advice on the next steps in their professional journey. Hearing different perspectives, fascinating new insightful questions that I never really considered when I was in their shoes and just meeting new people is always fun and truly a pleasure. I’m glad to hear that the stories I share are helping others which is the main point of this blog. I figured I can make an even more significant impact by addressing a few job related questions that have comec up as a guide that trainees can use to evaluate opportunities and chart the next steps in their journey.

Before doing so, I received some concerning feedback that I need to address here. These trainees told me they felt bummed and depressed after reading my last two posts, Everyone is Replaceable and The Four Routes to Profitability in IR: The Plight of the IR Opportunist. Some trainees wonder why they have worked so hard to get to where they are if there are incredible challenges and concerns regarding their future. They have unfortunately come to this realization ten years too late, so please spread the word about this blog to students and pre-meds.  I do not apologize for my words because most have not been told the truth about their existence, and the sooner they are aware, the better. Now understanding the truth does not mean that all hope is lost. This blog exists to support those who share my concerns regarding our future and to create an environment where we can help each other to change our circumstances. Part of this work involves sharing what I believe to be the truth. Consider it a counter-perspective to what most are exposed to in training. 

So yes, the financial future of medicine in the current fee-for-service environment could be better. None of this is new or novel information for those of us further along this path, but it may be new information for those just getting started. How we react to challenges is what will define us. Consider this an excellent opportunity for us to chart a better course forward. As vascular and interventional radiologists, we are brilliant and resourceful individuals, perhaps the best in all of medicine. The sooner we all think bigger and work to fight against disturbing trends, or at the very least exploit market inefficiencies to survive on our terms, the better we will all be.

The topic of today’s blog post is how to find the ideal opportunity out of training. Once upon a time, I was looking for a job, and I did a terrible job. Here’s how to avoid some of the mistakes I made. 

1. Understand Who is Giving You Advice

Depending on your ability to network, you will get lots of advice from different people. Most trainees rely on advice from mentors in academia. Yes, academics tend to get a bad rep on this blog. The truth is some academics in interventional radiology are hard-working, honest people who share many of my interests concerning a future of IR independence from DR. This sentiment is particularly true for academics early in their career, as I was reminded of this when having a great conversation with a former private practice IR turned academic IR over the phone recently.

The problem with advice from academic leaders is that many have never worked a day of private practice, let alone in office-interventional suites, so they don’t necessarily understand the challenges that over 80% of our workforce faces. Furthermore, the vast majority of academic physicians are employed by large healthcare systems which continue to consolidate and treat physicians like commodities. Finally, most academic divisions are still part of radiology infrastructures. As such, many in academia, including some very prominent leaders, have a natural conflict advocating for a future of IR independence. 

It would only be fair to you if I disclosed my inherent biases based on my personal experiences and propensity to practice independently at all costs. My advice is skewed towards those looking to find their path to entrepreneurship. There are many ways to have a meaningful career in medicine. Despite the challenges I’ve faced, I am genuinely pleased with my career trajectory. I have visualized success, and I am connecting the dots to accomplish my goals. My path is one of many ways to happiness in medicine, which is mainly internal and based on mindset more than anything.

In general, when asking for advice, always understand incentives. Some very prominent leaders in private practice love giving trainees advice. And for the most part, their advice is sound, but if they own their practices and are looking for labor, please understand their main objective and ask them about their exit strategy. The same goes for academic leaders looking to fill their faculty rosters with strong IRs. This isn’t to discount what these individuals say, but there will always be some underlying objective. Familiarize yourself with the concept of the “IR Opportunist,” and know that no individual is truly benign. 

2. Understand Yourself

I have written on this blog that 99% of physicians are not suited to embark on a path of independent practice. Many people practicing medicine as employees or partners for hospital-based groups are content with their existence. Some of my friends get to do work that they love doing and feel they are well compensated. Most of my friends look at some of the headaches I face and think I’m insane when there is a path with far less resistance that’s available. Some of these friends and mentors have offered me incredible opportunities to bail and enjoy the benefits they enjoy.

If you require some semblance of stability in your life, be it financial or otherwise, then the entrepreneurial path is not for you. You do not need to open an OBL. No, you need a job.

And that’s fine because the truth is that to be a good leader, you must learn to be a good follower first. And just because the vast majority do not transcend a career of working for others to pursue entrepreneurial endeavors does not mean that their work is any less important or impactful than the 1% of us who have a permanent chip on our shoulder and feel some necessity to do something different.

When figuring out your career, you must know yourself. What are your tendencies? What is your risk tolerance? Where do you see yourself in 5, 10, and 20 years?

Your Framework to Find Success

Here is the most important question one has to ask themselves:

Do you enjoy radiology?

If the answer to this question is yes, and you are nearing the end of an IR training program, then you should do yourself a huge favor and go find a traditional hospital-based radiology group. I’ve provocatively referred to this type of practice as “trash-collection” which offends certain people. I hate this type of practice for myself, but we cannot deny that a well-trained IR can become a “hospital MVP” because of their essential role in any inpatient setting. Traditional radiology practice lends itself to this role. Some people enjoy this type of practice. Many of these individuals liked a lot of the routine procedures they did in training. Few may end up in large and diversified groups, enabling them to have some semblance of an outpatient program as part of their group. I call these “good groups.”  Others find employment within healthcare systems, resulting in subsidization permitting more IR time and focus. Read older posts for more information regarding this practice model. Two recent Backtable VI podcasts have nicely highlighted stories of two early-career IRs in both hospital-employed and radiology group settings who are happy in their jobs. You can find them here and here. 

Do you want to practice “100% VIR”?

If you’re like me and rather gouge your eyes than be forced to churn RVUs for some radiology practice owner, then your options will be somewhat limited. Here are your options.

1. Find a “good group.”

“Good groups” generally permit close to 100% IR practice but do not use percent IR as a benchmark for clinically oriented practice. If 100% of your time is spent doing low-level procedures with no clinic, then is that a real IR job? While it may be to some recruiter who has no idea what they are talking about, you know as well as I do that it is a trash job. Unfortunately, there are a lot of those jobs out there.

An actual “good group” will allow you to have a clinic with at least one medical assistant, scheduling support, and marketing support to build an outpatient practice. Bonus points for the rare groups, generally in tertiary markets more than an hour outside of metro areas without behemoth healthcare systems, which have OBLs. Without the ability to build an outpatient practice, you will forever be subject to the whims of the inpatient infrastructure. This is not a reliable strategy for ensuring a practice where the IR focused on longitudinal clinical care will be professionally satisfied.

2. Get an academic job.

Academics can be an excellent opportunity for the right type of person. Every department varies somewhat based on leadership and local politics. The ability to work in what I hope would be a progressive system that encourages a clinically oriented practice with a longitudinal clinic should be attractive to young IRs. Furthermore, the ability to work with older faculty who can foster your professional development and trainees who will keep you honest is a good thing.

The huge negatives are working for a healthcare system, the subsequent lower compensation and the overall lack of control in a setting that expects you to partake in significant “homework” as part of your moral obligation to train the next generation of IRs and appease certain characters in your department who may not share your kind-hearted intentions.  The politics can be sticky, and the path to career growth largely depends on your boss’s vision and your ability to seek meaningful mentorship. As an outsider, I’ve observed that one’s ability to be promoted does not always correlate with one’s true leadership skills, clinical skills and knowledge. There’s a reason some faculty bounce around every few years like tech workers, no different than many of us in private practice. Identifying strong and morally responsible leadership is an important skill we must all develop. 

3. Get an OBL Job.

As the mindset and skillset of new-generation IRs continue to shift, there are more of you out there considering OBL work. While I am a proponent of OBL practices, there are some pitfalls one has to be mindful of when going down this route.

If you decide on an OBL practice right out of training, just know that the road is challenging. It is certainly not impossible, as people have done it, but it is generally not a recommended immediate path for two main reasons. First, it takes time to develop skills and intuition as an attending IR. In the OBL, the primary consideration is always patient safety. The room for error and the ability to have support tends to be less so than it is in traditional hospital-based practices. Second, taking an OBL job right out of training likely has significant future financial consequences. Your negotiation leverage is limited when you are fresh out of training with substantial debt and likely at the weakest point of your career regarding ability and local reputation. Many OBL owners will be excited about the prospect of a young IR coming in to “build the practice.” Many young IRs, myself included not too long ago, are excited to get a great job knowing that the alternative may not be that professionally satisfying. What may come from a potential marriage such as this is a short-lived opportunity after you realize a harsh financial truth:

You are setting yourself up to be low-priced labor for crafty practice owners with more leverage than you.

When you start building an IR Practice within an OBL, particularly within an OBL that does not offer IR services yet, you will undoubtedly increase the valuation of this practice assuming you are successful at building the practice. You need a pathway for equity ownership to make this worthwhile, particularly if you are tasked with the hard work required to obtain referrals. It is hard to have an equity conversation from day one, especially when you have no track record.

Regarding referrals, if you are not tasked with obtaining your own referrals with the support of the practice, you have to question how the practice is getting referrals. They don’t fall out of the sky, and certain OBLs have reputations for engaging in questionable legal arrangements with investing physicians or “partner” physician groups. Please talk to others in the space and hire a healthcare attorney before signing any contract. You don’t want to work for a practice that engages in unethical or illegal patient acquisition strategies. Financial alignment with potential referring sources may raise scrutiny and the potential for orange jumpsuits. 

With all these pitfalls explicitly stated, I have colleagues who have gone into OBL practices straight out of training and are doing well. This has often included joining practices with a senior physician available for mentorship and with an understanding that there is a path to equity ownership in the practice. These opportunities are rare, but they will hopefully be more common. For more information on OBL jobs, check out this older post. 

4. Do Locums Work

I have written about my experiences doing locums extensively on the blog. In general, my experience has been incredibly positive. I used to think this was not a great path for those coming out of training, but I have evolved to change my stance. For the right person, doing locums work can be a great option right out of training.

What are the advantages?

The first benefit is financial. The ability to make at least 2x what would make starting in a traditional employed setting is a huge boon, particularly for those with significant debt. In addition, putting oneself on sound financial footing early in your career allows significant leverage when considering future opportunities.

Second, locums work allows one to craft their professional existence to their liking. There will be a shortage of IRs for some time, and as such, there will be continued demand for locums physicians. The ability to choose where you want to practice, how you want to practice, and when you want to practice is huge. Flexibility is wonderful and puts the power back in the hands of physicians who have worked so hard to get to where they are.

The ideal first locums opportunity would be in a busy hospital with another on-site IR. There are a few of these opportunities out there. They may not be in one’s preferred geographic location, but it’s not a bad option for the flexible graduate.

There are several pitfalls. First, there is no stability in locums work. Market conditions can change, which means things are constantly in flux. I’ve had contracts canceled last minute, which would be very stressful if I was not in the financial situation I am in halfway through my fifth year of practice. Second, moving between several sites can be particularly jarring if one has not developed a cadence or sense of self with their skills and abilities as an IR. It takes time to establish that cadence. I’d be lying to you if I didn’t admit that I’m still fine-tuning that myself. There are no shortcuts. Finally, coming out of training, one is unlikely to find an OBL opportunity for locums work as OBL owners and operators will want experienced IRs to cover their facilities.

Furthermore, those relationships take time to cultivate, which means the most likely opportunity will be in hospital-based facilities. While a hospital is a great place to be right out of training, it also means there will be added time for credentialing and moving through the terrible red tape that plagues most healthcare systems. While many will have to do this only once when signing onto a “permanent job,” you will find yourself doing this a lot when adding multiple locum contracts. It is an absolute pain. 

Understand Yourself and What You’re Willing to Sacrifice

For 99% of you, you need a job; ideally, one that you think will be a good long-term fit. The truth is that for many of us, our first job isn’t our last job. One thing to keep in mind for everyone, whether you’re looking for a job to keep for the long haul or if you’re a future physician entrepreneur with OBL/ASC dreams, a career is like a scenic marathon. Always keep the end goal in mind and be comfortable with the fact that uncertainty is ok and you may have to do something that isn’t ideal for a while to get to a point where you will be happy. 

For those looking to practice vascular and interventional radiology at the highest level with no diagnostic responsibilities, adequate support for a longitudinal clinic, and the overall ability to build a practice from day 1, you will likely be disappointed. Unfortunately, the vision I have for our future, shared by other vocal individuals in both private practice and academia, will take time to become mainstream in our space. 

When it comes to jobs and sacrifice, there are three main factors one needs to consider:

1. Job
2. Location
3. Money

They used to say you get ⅔. The truth is that you are more likely only to get ⅓.  I think it’s possible to have all three, but they will never be handed to you. You have to build it for yourself, which is a matter of time and careful execution. 

If I Had A Redo

Hindsight is always 20/20, but if I had to do one thing over again, I would have spent more time thinking about my tendencies and establishing a vision for myself as a vascular and interventional radiologist. Instead, it took me doing something I hated and subsequently leaping into a promising space on unfavorable terms to figure out what I wanted. I could have shortened the process by networking better and understanding the financial drivers of practice in various settings. Simply meeting many IRs, including those taking a path I’m not personally excited about, has been so helpful in me figuring out what exactly I want out of this career. 

Final Thoughts

1. TLDR

If you like being a radiologist, be a radiologist who does procedures. If you don’t like that, then don’t do it. Your choices then become finding a “good group,” going the academic route, getting an OBL gig, or doing locums as a bridge to permanent employment or practice ownership (my path). 

Some other gems from a few of my friends:

• Take whatever is promised to you and correct it by a factor of 0.3-0.5. 
• Get everything promised to you in writing.
• Try to minimize or eliminate any restrictive covenant. 
• Get your employer to cover tail-insurance for claims-based policies. 
• Establish pathways to equity ownership up-front. 
• Assume a private equity sale is imminent. 
• Know your worth.

As always, thanks for taking the time to make it this far. Over the next several months, I’ll roll out more articles with actionable content, including how to evaluate jobs and what to look for if interested in practicing longitudinal patient care. I’ll also do a deep dive into locums.