Young Urologist Manual | 2020

5 TH Edition

AUA YOUNG UROLOGISTS COMMITTEE

Transitioning from Residency to Practice Manual

WHAT'S NEW:

Entering a Competitive Market Academic Urologic Practice 2020 CPT ® Codes

PREFACE:

TRANSITIONING FROM RESIDENCY TO PRACTICE

Navigating your new career path? Questions about transitioning into practice?

The American Urological Association’s (AUA) Young Urologists Committee (YUC) has prepared this manual to guide residents and young urologists during the transition from training to independent practice. While questions such as, “which type of practice should I enter?” “how do I negotiate a contract?” and “how do I get paid?” are critically important as you navigate your new career path, they may not have been top of mind to ask faculty mentors when working through the rigors of residency and fellowship training. This manual should not only serve as a guide as you determine what type of practice to enter, but can also help you consider important factors when deciding where you would like to practice as well as provide information on the job search process, contract negotiations, and physician compensation models. Most importantly, this guide also offers wellness tools to help optimize work-life balance and combat burnout.

This year’s edition includes two important additions. The first addresses challenges young urologists face when entering a competitive market such as a large metropolitan area or a subspecialty that is saturated. In this section, Drs. Sammy Elsamra, Adam Kadlec and Jay Simhan provide practical tips to help young urologists overcome the unique challenges associated with establishing a practice in these complex and challenging markets. The second addition focuses on entering into an academic practice. Drs. Elsamra, Kyle Richards and Benjamin Ristau discuss how entering academia offers both advantages and disadvantages over other practice models as well as relevant tips on how to succeed in an academic environment regardless of subspecialty or practice location. Finally, both the Financial Management and Military Urology sections have been revised to include new and updated information.

I would like to thank the entire Young Urologists Committee, especially Chair-Elect Dr. Kyle Richards, for their hard work and commitment to this Committee and to the AUA. Additionally, the activities of this Committee would not endure were it not for the hard work and commitment of Ms. Sarah Loughlin, the YUC’s AUA staff liaison, to whom we are all incredibly grateful.

I wish each of you great success and fulfillment in your early careers and beyond. Please feel free to email your comments, questions and feedback to youngurologists@AUAnet.org. Updates to this manual are made annually, and we rely on your input to make it better each year.

Steven J. Hudak, MD

Young Urologists Committee Chair (2019-2020)

Additional resources, including podcasts, webinars and more for early-career urologists and trainees can be found here:

• Young Urologists section of AUAnet.org: www.AUAnet.org/youngurologists

• Residents and Fellows section of AUAnet.org: www.AUAnet.org/rfc

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TABLE OF CONTENTS

1. DETERMINING WHAT KIND OF PRACTICE TO ENTER........................................................................................................ 5 2. APPLYING FOR THE POSITION.......................................................................................................................................... 6 3. NEGOTIATING CONTRACTS............................................................................................................................................ 11 4. PHYSICIAN COMPENSATION MODELS........................................................................................................................... 12 5. FINANCIAL MANAGEMENT............................................................................................................................................ 14 6. DEFINING YOURSELF...................................................................................................................................................... 18 7. WORKING WITH ADVANCED PRACTICE PROVIDERS (APPs)........................................................................................... 20 8. WOMEN IN UROLOGY: UNIQUE CHALLENGES............................................................................................................... 22 9. WELLNESS FOR UROLOGISTS..................................... 26

10. CONTINUING EDUCATION & PRACTICE MANAGEMENT.............................................................................................. 27 11. UNDERSTANDING PUBLIC POLICY AND GOVERNMENT ADVOCACY............................................................................ 31

Appendix

A. PRACTICING IN A COMPETITIVE MARKET..................................................................................................................... 32 B. MORE ABOUT ACADEMIA..............................................................................................................................................34 C. MORE ABOUT RESEARCH.............................................................................................................................................. 35 D. PERSPECTIVE: PRACTICE TYPE AND LOCATION............................................................................................................. 37

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AUA Young Urologists Committee

Transitioning from Residency to Practice

Chief Editor: Steven J. Hudak, MD

Members of the 2019-2020 AUA Young Urologists Committee:

Steven J. Hudak, MD – ChairKyle A. Richards, MD – Chair-Elect

Sero Andonian, MD, MSc, FRCSC, FACS – Immediate Past-Chair

Clint Cary, MD – American Medical Association LiaisonSammy E. Elsamra, MD – New York Section

Erik Grossgold, MD – Society of Government Service Urologists (SGSU) Liaison

Bruce Jacobs, MD – Northeastern SectionForrest Jellison, MD – Western SectionAdam Kadlec, MD – North Central Section

Kevin Koo, MD, MPH, MPhil – Residents and Fellows Committee Liaison

Mark Memo, DO – Doctor of Osteopathy Representative

Jay Raman, MD, FACS – American College of Surgeons Liaison

Julie M. Riley, MD – South Central SectionBen Ristau, MD – New England SectionJ. Patrick Selph, MD – Southeastern SectionJay Simhan, MD – Mid-Atlantic Section

Tricia Zubert, MSN, APRN, CNP – APP Membership Committee Liaison

Sarah Loughlin – AUA Staff Liaison

Contributing Authors:

Nathan Grunewald, MD Todd Lehrfeld, MD Dima Raskolnikov, MD

Mathew Sorensen, MDRussell Williams, MDJonathan Wingate, MD

Acknowledgement: This guidebook has been adapted from the original AUA Young Urologists Guide, “Transitioning from Residency to Practice” and includes content from the “Business and Communication” section of the AUA Core Curriculum. Unless otherwise stated, content in the guide should be viewed as opinions and perspective from the authors, and not as official positions of the AUA or professional career, legal or financial advice.

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1. DETERMINING WHAT KIND OF PRACTICE TO ENTER

Academia? Large group? Small group? Hospitalbased? Decide what fits best for you.

Practice types are generally divided into four broad categories – hospital-based, private practice, academia and military practice. Read more about each below.

NOTE: Three young urologists share their personal perspective on practice type and more in Appendix D.

1.1 Hospital-Based

Salaried employment as a hospital-based physician can be seen as a way to escape the increasing administrative burdens of the profession and/or achieve a more satisfactory lifestyle – especially in a health care environment that is in flux.

Advantages:

• Guaranteed salary (typically with an incentivized plan)

• Built-in retirement plans

• In-house management of administrative affairs (e.g., human resources oversight, billing and collecting, rent and overhead, daily operations management, etc.)

Challenges:

• Not being in charge

• Patient population defined by the needs of the hospital system

• Possibility of compensation changing and/or being evaluated on pre-determined metrics (e.g., quality and patient satisfaction measures) as part of your overall compensation plan

Unique opportunities in this practice type include the ability to climb the career ladder to manage multiple practices or become a leader within the organization.

Hospitals may be a stand-alone entity or part of a hospital network such as Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Veterans Affairs, an HCA (Hospital Corporation of America) affiliate, etc. If considering employment at a hospital, become familiar with the satisfaction level of the physicians employed there. Consider reaching out to current contracted physicians at the hospital for a better understanding of their satisfaction level with their contracts. Reaching out can also provide you with an opportunity to ask questions and seek advice that may help in negotiations.

1.2 Private Practice

Private practices can be organized as a corporate model (where physicians are shareholders) or where one or more physicians owns the practice and employs other physicians or providers. Physicianpractices are often incorporated for tax benefits as well as to protect owners from liability. Owners generally take a salary draw, split any receipts after all expenses are paid, and typically distribute receipts monthly or quarterly; it is often an “eat what you kill” model. This practice type can include solo practices, small or large single-specialty groups, or a multi-specialty group.

Advantages:

• Often provides more control over how one individually practices, including the physical set up, management of the electronic health record (EHR)/health informatics system(s), employee selection and what type of patients are seen and how they are treated

• Generally allows for decisions to be based on the interests of the owners/stakeholders versus those of an entire health care system

• Partial ownership in the corporation can provide financial incentives separate from those received when caring for patients in the clinic, hospital, or operating room

Challenges:

• Compromising with the interests of partners that may differ from yours

• Nurturing referral sources and partnering with hospitals for mutually beneficial outcomes

• Partial ownership usually requires an initial investment of time and/or capital to “buy in” to the corporation. This requires the new urologist to acquire a certain amount of fiscal risk

1.3 Academic Practice

Academic urologic practice typically entails being hired by a medical school, cancer center, or large hospital system as part of an academic department or division of urology (often the primary site of a sponsoring residency program). One will generally have a rank position within a university or academic structure (clinical instructor, assistant professor, associate professor, professor, etc.) with responsibilities of (and resources for) research, education, and administration. Academic practices still rely on clinical productivity in order to provide salary and benefits unless grant funding subsidizes

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a portion of your salary (depending on the budget approved in the grant).

While most academic practices are administered by the division or department of urology within a medical school or cancer center, they can also exist as employed positions within large tertiary care medical centers with an academic affiliation (perhaps a secondary rotation site of a residency program). Working in a county hospital or VA medical center may also be part of an academic career, as these faculties often participate in the academic affairs of the sponsoring university.

Hybrid academic positions also exist at private practice groups that service academic medical centers. While opportunities outside of an academic medical center to educate trainees and conduct research certainly exist, academic medical centers typically offer the ability to provide specialized tertiary urologic care in an environment where research and education are prioritized. A hybrid position may be advertised as being able to provide an “academic appointment and academic career,” but unless the setup supports attending conferences, conducting and presenting research, and plays an integral role in the education of medical students, residents, and/or fellows, those critical academic functions may be sacrificed for clinical productivity as required by the practice.

In addition to a busy clinical practice, most academic urologists have the ability to shape the future of urology through research and/or teaching the next generation of urologists. For most (but not all) academic positions, fellowship training and sub-specialty practice is becoming the norm. It is important to look for programs that have a need for your specific area of expertise and interest.

More about this practice type can be found in Appendix B. In addition, more about research as a job function (including funding, clinical trials and more) can be found in Appendix C.

1.4 Military Practice

Practicing urology while serving your country offers a breadth of rewarding practice opportunities, as well as chances to go places and do things you would not otherwise have had the opportunity to do within civilian medicine. Military urology positions can range from single-urologist practices at smaller military hospitals in the U.S. and abroad to academic tertiary care hospitals associated with large military installations. Many of these positions are filled by individuals who attended medical

school on a military scholarship program and/or completed residency training at a Military Treatment Facility (MTF), although direct accession into the active or reserve military force is possible. Interested individuals should contact a recruiting office (Army, Navy, Air Force) and ask to speak specifically with a recruiter well-versed in physician recruitment as well as one or several military urologists.

Residents and fellows preparing for a military medical career should become familiar with their service branch’s strategic needs related to fellowship opportunities and practice locations available after training. Military urology leaders differ for each branch of service (Navy Specialty Leader; Army and Air Force Consultant to the Surgeons General). These leaders ultimately determine assignments for each of the urologists within the active force. Thus, it is vital to proactively engage these leaders years before assignments are made to ensure the preferences of the young urologist can most closely align with the needs of the service. It is also critically important to convey any special requests (e.g., family health considerations, civilian spouse employment, etc.) so that they may be considered as assignments are made. Once in practice, these service leads will remain an important resource for information about career advancement, military-unique training opportunities, and alternative practice locations. It is also helpful to engage other practicing military urologists to seek career guidance and overall professional support.

After fulfilling one or several active duty service commitment(s), most military urologists transition to civilian urology practice. Federal agencies such as the Department of Veterans Affairs, the Indian Health Service and Military Reserves have programs that credit the time in service, which applies the active duty service towards a federal retirement plan. Each program is specific and is subject to change. It is essential to investigate these benefits before transitioning from military service, while future contracts are being negotiated.

2. APPLYING FOR THE POSITION

2.1 Location

A key factor to consider when applying for jobs is geographic location. Research the areas that interest you. Is there a high density of urologists? Are the competitive markets already saturated with urologists (note: more about practicing in a competitive market can be found in Appendix A)? Are there less competitive areas with fewer urologists? What

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are the typical payer mixes for these regions? What types of insurance do the patients have?

In addition to these factors, it’s also critically important to consider whether or not the city or practice location is desirable from a personal perspective. If applicable, is the location desirable/ offer employment opportunities for your spouse/ partner? Become well versed with the social opportunities in the vicinity if that is important to you. Dining, night/family life, and school systems can all play a significant role in choosing a location to practice.

NOTE: Three young urologists share their personal perspective on location and more in Appendix D.

2.2 The Job Search

In today’s medical job market, urologists are in high demand. A tightening workforce in urology has caused the demand for well-trained urologists to skyrocket. It’s not uncommon for a graduating urologist to receive 9 to 12 job offers prior to selecting a location to practice. Still, it’s important for graduating trainees to begin the job search early.

As in all fields, networking and connections can oftentimes lead to job opportunities. Personal recommendations via networking can be one of the best ways to start your job search. Groups looking to hire will often contact program directors in search of graduating residents or fellows. Leverage your attendings, advisers or program director to see if they know of a job opportunity that aligns with your goals. Even if they don’t, they may be able to direct you to someone else who does.

Academic positions are often not widely advertised, but come about by word of mouth. If pursuing an academic position after fellowship, your fellowship director or mentor will often be able to identify available positions via their own network. You’ll also want to rely on your own contacts within professional associations/societies. Many times, preliminary interviews happen at major urologic conferences (e.g., AUA Annual Meetings or AUA Section meetings) or at sub-specialty meetings.

In addition to networking, consider the number of other ways to find a job that best suits your needs.

Career fairs can be a good way to begin the job search, as they provide an opportunity to engage with numerous employers, recruiters and groups in a relatively short period of time. Working with a recruiter is another way to learn about job opportunities: a good recruiter will consider your

needs and recommend you accordingly to employers who seem to be a good fit. In addition, the AUA’s online career center (JobFinder) and classified advertisements in medical journals and publications such as JAMA, The Journal of Urology ® and Urology Times also publish job postings. Lastly, don’t be afraid to leverage social media: Doximity, LinkedIn, Twitter and Facebook provide an opportunity to network while being mobile.

Job Search Resources

• JobFinder: AUA’s Online Career Centerwww.AUAnet.org/Jobfinder

• Veterans Affairs Job Postingswww.va.gov/jobs

2.3 The Curriculum Vitae

Doctors use a Curriculum Vitae (CV) to apply for employment. More common in the academic world and within international medical communities than a résumé, a CV is typically longer than a résumé and provides more detailed, relevant information to employers about your achievements as a physician.

To be effective, a CV should be as up-to-date as possible, be flexible enough to speak to any opportunity for which you are applying, and include your achievements, experience, skills, education, special research projects and publication credits.

Below is a formula you might consider when crafting your CV. [https://www.wikihow.com/Write-a- Doctor's-Curriculum-Vitae]

1. Begin with contact information. On the top of your first page, list your full name and credentials, address, phone number(s), pager number, fax number and email address(es).

2. Write a brief objective or career statement. This should be a one or two sentence summary of your current position and your professional goals. Example: I have completed a fellowship in minimally invasive surgery and have extensive experience in robotic surgery. I am seeking a position in the private practice environment as a urologic cancer surgeon.

3. List any board certifications, including the dates national examinations were taken and passed. Include a list of states where you are licensed.

4. List your educational history and your professional experience. Share your educational credentials by starting with the most recent institution you attended, and list the schools, degrees and years of attendance. Include any relevant activities you participated in while

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a student/resident/fellow. List all awards and honors you have received.

5. Include a section for professional successes. List any research you have conducted, publications you have written, any teaching you have done for the American Urological Association and awards you have received.

6. List the names and contact information of three or four professional references. It is very important to ask your references if they can be included on your CV and provide them with a copy of your CV in case they are contacted.

7. Include memberships of professional organizations or associations, along with leadership roles held.

8. If you have any gaps in your education or training, it is recommended that you explain the breaks as it may come up in your interview. It is better for you to take control of the gap than to leave it without an explanation.

9. For first time job seekers, it is suggested that you include information about your residency and any relevant volunteer experience.

10. Share all languages that you speak, including your level of fluency.

Tip: Always have an updated CV published and accessible online.

2.4 The Cover Letter

A cover letter can be an important part of the application. If the letter doesn’t attract the attention of the person reading it, your entire application package could be discarded. Tips for successful cover letters include the following:

1. Address the letter to a specific person (e.g., the hiring manager or hiring physician) when possible.

2. Use bullet points to differentiate yourself as someone who can excel in the position. Clearly define yourself and your unique skills. Example: As an experienced male infertility and erectile dysfunction expert, I routinely:

• Perform microscopic vasal anastomoses

• Perform penile prosthesis surgery

• Treat Peyronie’s disease with synthetic and auto grafts

• Work with a reproductive endocrinologist for assisted fertility cases

• Market and promote Andrology to the community and to potential referring physicians

• Publish articles in peer-reviewed literature on these topics

3. Underscore your commitment to the position by including that you will be calling the hiring manager at a specific time (within a week of submitting your application) to follow-up.

4. In the signature block, along with your name and credentials, include the following:

• Phone number

• Email address

• Any relevant social media handles (i.e., LinkedIn, Twitter, etc.)

2.5 The Interview

Congratulations, you’ve been invited for an interview! Now what?

The interview process and site visit allow both the candidate and employer the unique opportunity to not only meet face-to-face, but also to determine if the proposed relationship is a good match for both sides. Nothing can influence an interview more – either negatively or positively – than the interviewee’s preparation or lack thereof. A candidate interviewing for a position should know some of the institution’s history and be familiar with the individuals already in the practice and their area of interest or specialization. Much of this information can be found easily online.

It’s a good idea to practice for the interview before you “go live.” If possible, schedule mock interviews with colleagues who are in the same position. If you currently work at a hospital, ask the human resources department to practice with you for an interview. Most departments will be happy to accommodate you and help you with interview preparation.

Anticipate what questions may be asked during the interview (e.g., “What can you or your skill set bring to the practice that we don’t already have?” or “Why do you think this practice would be the best fit for you?”). Rather than memorizing a scripted answer, prepare three or four talking points so you can respond naturally.

If necessary, take care to also prepare responses to address anything that could be perceived as negative that may come up in a background check (e.g., a past DUI citation, arrest or other previous punitive

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actions). As nearly every practice does a background check as part of the interview process, it’s important to be truthful and upfront about such incidents. Offering a transparent explanation for gaps in your training or work experience is also important. It is far better to offer a truthful account with a positive spin (i.e., what have you learned from the experience?) than trying to conceal it.

If interviewing at a hospital, a candidate is likely to meet primarily with the physician recruiter who serves as the liaison during the interview and negotiation process. You may also visit with the Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Chief Nursing Officer, OR supervisor, OR specialist (urologist) and/or members of the marketing department. Be prepared for each of these interactions.

When interviewing for an academic position, giving a Grand Rounds-style lecture during your interview period is typical. While preparing for your interview day, reflect on the factors that interest you in academic practice. Are you a researcher? If so, what kind of research do you want to do (e.g., bench vs. translational vs. clinical trials vs. big data)? Are you interested in education? If so, what kind of education (e.g., undergraduate medical education, graduate medical education, etc.)? The answers to these questions can help provide the program with a sense of what you bring to the table. Remember, you are interviewing the program as much as they are interviewing you: be sure to ask questions about the kind of support you think you will need for your non-clinical academic interests.

During the interview itself, make an effort to connect with the interviewer on some level. This connection could be anything related to the job itself or a particular interest in the medical practice. It could also be a personal connection such as a mutual interest in a particular hobby or time spent outside of work. Connecting with the interviewer can differentiate you from other candidates as well as demonstrate your sincere interest in the position.

Additional Tips:

• While this may be obvious, take care to arrive early to the interview. Never show up late. Dress appropriately. If there is a question about the attire, it is better to dress too formal than appear too casual.

• Follow the cardinal rule of interviewing: never say anything negative about your former institution, colleagues, residents or students.

• Highlight yourself as a team player. Provide positive examples of your participation in team sports, clubs or societies. Any leadership positions held in any of these activities are certainly worth emphasizing.

• Smile. Sit up and lean slightly forward to convey interest. Be enthusiastic. It is desirable to be remembered, but you want to be remembered in a positive light, so avoid being “over the top” when trying to impress or making a statement if it’s not an authentic reflection of your personality.

• Although salary and benefits are important, it’s not advisable to bring up salary as the first question you have. An employer will expect to answer this question but avoid making it your first question or concern. However, do your research: most of the time, you can get a pretty good idea of salary ranges and benefits from publicly available documents. The benefits package for most universities will be clearly delineated and, likely, non-negotiable. In public institutions, base salaries are a matter of public record (although bonuses and incentives may not be). Salary ranges may be a little more difficult to determine for a private institution where the data is not necessarily made public, but comparing salaries at nearby public institutions can give you a solid idea. Read more about compensation models in Section 4.

At the conclusion of the interview, ask for contact information (such as a business card) for each of the interviewers. Send a thank you or follow-up letter to each individual either via a mailed, hand-written note or by email. Include specific information that was discussed during the interview; including a memorable anecdote or connection can also be helpful.

A successful interview will lead to an employment agreement from the practice or group. Read more about Contracts and Negotiations in Section 3 and before accepting, consider visiting the location again. If you have a significant other and/or family, discuss having them visit as well. Become familiar with the neighborhoods and the areas’ housing market. After all, this will be your new home.

If you aren’t finding success or direction with your job search, another option is to consider working as a locum tenens physician for a while. Locum tenens provides the opportunity to experience a range of practice conditions and locations, and can help determine what the best job for you actually is. Other advantages include good pay, lodging that is usually provided, and some locum tenens jobs include the option for permanent

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placement if the “fit” is good.

2.6 Resources

• JobFinder: AUA’s online career learning center offers free resources and videos on the topics of Standing Out by Building Your Brand, Networking for Job Search and Career Success, Avoiding Job Search Sabotage, Acing the Interview and more.

https://careercenter.auanet.org/jobseekers/ resources/blueskyLMS/

Job Search Timeline for Residents and Fellows

MARCH/APRIL

Prior to your final year of training (i.e., fourth year of a five-year residency or first year of a two-year fellowship)

Schedule a few “meet and greet” sessions with colleagues to discuss job opportunities, locations and types of practices during the AUA Annual Meeting in May.

AUGUST/SEPTEMBER

During your final year of trainingBegin interviews and hospital/practice visits.

JANUARY/FEBRUARY

During your final year of training

Complete contract negotiations and finalize employment selection.

Figure 1: It is extremely important to follow this timeline to avoid scrambling for a job. Limited options weaken the ability to negotiate effectively.

3. NEGOTIATING CONTRACTS

You nailed the interview and received an employment agreement contract – congratulations! What’s the next step? Many physicians recommend hiring an attorney to assist in contract negotiations. Remember, any contract you sign is a legal document, so having your own legal counsel (or two) review the contract in detail to protect your interests is to your advantage.

3.1 Needs/Requests

Consider the following and whether or not they should be included in your contract:

• Equipment°

°

°

Office-based equipment (laptop or desktop computer, flexible cystoscope, ultrasound, etc.)

Hospital-based equipment (full complement of flexible and rigid endoscopes, surgical instruments, etc.)

Special equipment (surgical robot, ultrasound equipment, operative microscope, surgical LASERs, etc., and an appropriate amount of dedicated surgical “block time” for use)

• Personnel Requirements°

°

In your office: nursing and ancillary staff members

In the hospital: Will they provide appropriately-trained personnel for surgical procedures? It’s especially important to be staffed with a qualified assistant for procedures such as robotic surgery, ESWL and microsurgery.

3.2 Understand Compensation

Typically, a hospital will guarantee your salary for one to two years. A suggested negotiated length of an initial contract is three years with frequent evaluations and/or meetings to track progress toward target productivity endpoints.

Key questions to consider include:

• Does your contract specify that you’ll be evaluated on a quarterly basis?

• Will you be reimbursed based on your work Relative Value Units (RVUs)?

°

NOTE: Though contracts will vary, the RVUs are based on national guidelines with an average RVU production of 9,000-10,000 per year. Academic positions generally have a lower RVU requirement to accommodate research activity.

• Will you be paid additionally on a quarterly basis?

• How will you be compensated if you exceed expectations?

°

One suggestion is that the physician is paid 75% of any overage of professional fees collected with the hospital keeping 25%.

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Be aware of the billing and collections process, as a hospital may have several other physicians in different subspecialties on their payroll. Therefore, be mindful of the following:

• Ensure billing and collections for you is handled promptly and that appeals to third-party payers are processed in a timely fashion.

• Review and audit your own surgical case logs and RVUs.

Read more about compensation models in Section 4.

3.3 Contract Renewal

Review the policy for continuing your contract. Contracts can be terminated based on factors such as performance, professionalism or surgical outcomes. It is important to have a 90-120 day termination notice in your contract to have enough time to relocate and move to a new practice location if necessary. While contracts usually suggest a 30-60 day window, this may be inadequate.

3.4 Vacation/Time Off

Contracts typically provide 15-20 vacation days per year and national holidays off as part of its time-off package. Be sure this is included in your contract. Emergency room coverage and home call assignments should be clearly defined: you should know if inpatient, ER, and home-call responsibilities will be shared with other urologists on staff or if you are expected to be continuously on call. Weekend obligations should be clearly defined as well. For example, will the “on call” urologist covering your practice round on (and provide care for) your patients currently admitted (i.e., patients who have recently had surgery), or will you need to make weekend rounds on your inpatients even when not on call?

The contract should also state exactly which hospital(s) you cover for call, how often, and whether call coverage is included in your reimbursement package or if call is paid separately on a per diem basis. Additionally, some hospitals do not require urologists to be on call once they have reached 60 years of age, so determine how/if that could impact your call schedule (based on your age and the age of the other urologists in your call pool).

3.5 Malpractice Coverage

Malpractice insurance for doctors comes with tail or without tail. “Tail” is coverage that takes effect once you leave a place where you were employed and

practicing. This insurance covers any lawsuit that is submitted to the court on behalf of a patient you treated from the time of you leaving this job until the statute of limitation runs out for a lawsuit to be submitted to the court. This type of coverage can get quite expensive depending on the state, so be sure you know who is expected to cover this.

Once you’ve signed your contract, begin the credentialing process for the hospital as soon as possible. Credentialing can take up to six months to complete. Many hospitals have a separate credentialing process for surgical LASERs and robots. Obtaining credentials in these areas usually requires documentation of platform-specific training and submission of a 12-24 month caselog. Proactively save documentation supporting your training/experience and notify your program director and/or department chief that they may be contacted to validate your credentials in these areas. Additionally, be aware that each insurance carrier has its own credentialing process. You should be fully credentialed by the time you start your practice so that you can immediately treat patients and thus generate revenue. Be aware of additional state or medical board requirements including fluoroscopy, LASER, or jurisprudence certification.

4. PHYSICIAN COMPENSATION MODELS

Most providers are reimbursed for services through several “payers,” including federal and state government programs (e.g., Medicare, Medicaid) and insurance programs offered through employment and individual plans.

Reimbursement usually involves a payment as a percentage of the total bill received and is often impacted by standards set by Centers for Medicare and Medicaid Services (CMS) as well as by negotiations between the provider and regional insurance companies that the provider is contracted with. A co-payment is a small percentage of the bill paid directly by the insured patient. A premium is a monthly charge to the patient in order to stay covered.

There are two basic compensation models with variations: pure productivity and base plus bonus. Guaranteed total salary is not common, but several healthcare systems (e.g., Kaiser Permanente), government positions (e.g., Veterans Administration), and/or academic positions may offer this. The various payment structures are described below.

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4.1 Fee-for-Service vs. Value-Based Care

The fee-for-service model compensates physicians based on the amount of services provided to a patient and is a common payment structure seen in both private and public practices. This varies from other payment structures such as the concept of capitation, which involves paying a provider a fixed amount of money per patient over a pre-specified period of time. Potential issues that arise with each of these payment methods relate to the possibility of incentivizing providers to “overtreat” or “undertreat” patients.

CMS is promoting payment models that pay for performance in lieu of service. These models tie bonus payments to the quality of patients’ care rather than to how many or how few services are provided. CMS’s primary program is the Quality Payment Program, which was launched in 2017 and features two tracks: (1) Merit-based Incentive Payment System (MIPS), and (2) Alternative Payment Models (APMs).

MIPS is composed of four categories (Quality, Cost, Promoting Interoperability, and Improvement Activities), and participants must complete required components from each category. Participants receive a score based on the amount and quality of reporting they complete. Those scoring above the minimum threshold will receive a bonus of some degree; however, those that do not achieve the minimum threshold will be penalized.

While MIPS moves away from fee-for-service, APMs do so to an even greater extent through value-based payments. Participants must be part of entities set up to share both the costs and risks associated with serving patients. CMS requires the use of technology and metrics to be able to measure the value of the care given as well as the amount of risk the entity must bear. If successful, the financial benefit of being in an APM is more than that of MIPS participation. However, at this point, as it is difficult to qualify for APMs, there may be limited options for participation in this track.

CMS amends both MIPS and APMs each year, so it is important to monitor changes to the programs and look to the AUA for resources.

4.2 Relative Value Units

There are many models currently based on Relative Value Units (RVUs). These are pay-for-performance models where the physician’s training, skillset and time expended to provide a given service are taken into account when establishing compensation. Compensation based on RVUs provides a model

that focuses on value-based healthcare more so than the fee-for-service, volume-based model attached to the number of patients a provider sees or the amount of revenue the provider bills for or collects.

RVUs are part of the system Medicare uses to decide how much it will reimburse physicians for each of the services and procedures covered under its Physician Fee Schedule, and which are assigned Current Procedural Terminology (CPT) code numbers. The dollar amount for each service is determined by three components:

1. Provider’s work effort

2. Practice expenses associated with producing the service

3. Professional liability insurance expense

Each of these three components is assigned an RVU; to account for variations in living and business costs across the country, each of the three components is multiplied by a factor known as the Geographic Practice Cost Index (GPCI). The three components are added together and the resulting sum is multiplied by a dollar amount known as the conversion factor set by CMS on an annual basis to arrive at the reimbursement dollar figure.

RVUs are determined as part of the Resource Based Relative Value Scale (RBRVS), a system to describe, quantify and reimburse physician services relative to one another. A panel of physicians representing every sector of medicine, known as the Relative Value Scale Update Committee (RUC), reviews the values in the RBRVS scale periodically.

The primary purpose of work RVU compensation models is to align the provider’s compensation to the productivity (as measured by work RVU). This is completed with the use of independent compensation surveys and analysis of expected productivity. The most commonly used “government endorsed” surveys to accomplish this task are:

• American Medical Group Association (AMGA) Medical Group Compensation and Financial Survey

• Medical Group Management Association (MGMA) Physician Compensation and Production Survey

• Sullivan Cotter and Associates, Inc. (Sullivan Cotter) Physician Compensation and Productivity Survey

The most common methods of clinical compensation arrangements utilizing work RVU are:

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1. Compensation per work RVU: Also known as an “eat what you kill” model. Providers are paid a set dollar conversion rate for each work RVU generated.

Example 1.Work RVU $/Work RVU Compensation8,000 $50 $400,000

2. Graduated scale: Under this model, providers are paid dollar conversion rates per work RVU based on a graduated scale.

Example 2.

Work RVU Scale

$/Work RVU

$/Work RVU

Compensation

0 - 2,666 2,666 $45.00 $119,970

2,667 - 5,333

2,666 $50.00 $133,300

5,334+ 2,666 $55.00 $146,630APPROXIMATE TOTAL: $400,000

3. Base guarantee plus productivity bonus: Under this model, providers are paid a base guarantee and receive incentive/productivity compensation for every work RVU generated above a predetermined threshold.

Example 3.Base Salary Threshold Work RVU

$266,650 5,333 8,000$/Work RVU Bonus Compensation$50.00 $133,350 $400,000

4.3 Bundled Payments

The Bundled Payments for Care Improvement (BPCI) initiative was developed by the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries. Provider and hospital expenses are linked to make a single payment for an episode of care with bundled payment models. There are several bundled payment models, including the Oncology Care Model. In this model, oncology practices receive monthly care management fees and are eligible for bonus payments if they lower overall Medicare spending and meet quality goals for episodes of chemotherapy and related care.

4.4 Resources

• https://www.amga.org

• https://www.sullivancotter.com

• https://innovation.cms.gov

• https://qpp.cms.gov

5. FINANCIAL MANAGEMENT

This section was authored by Dima Raskolnikov, MD, Jonathan Wingate, MD and Mathew Sorensen, MD. Note from the authors: this text does not constitute professional financial, accounting, legal, or any other advice; we recommend consulting a professional if such services are desired. The products referenced below are meant as examples and are not specifically endorsed by the authors or the AUA.

The purpose of this section is to provide a framework for you to consider critical aspects of financial management during an important time in your career. It is not meant to be exhaustive. Just as it wouldn’t be possible for you to decide whether academic medicine or private practice is a better fit solely by reading this manual, so too with decisions related to personal finance. Instead, this section is meant to serve as a guide for further reading and discussion. We hope that you find it helpful.

Census data suggests that you now earn – or are likely to soon earn – approximately $350,000 annually. What should you do with this money? The right answer involves a combination of the ideas described below, tailored to your specific circumstances, goals and values.

5.1 Emergency Fund

How would you fund living expenses if you lost your job, had a medical emergency, or were unable to see ambulatory patients due to practice restrictions placed during a global pandemic? This is the point of an emergency fund. Before considering saving for retirement or any other long-term goal, set aside 6 months’ worth of living expenses in an account that you can access quickly and without penalty. The amount you select depends on your other financial needs and risk tolerance. Emergency funds typically take the form of a savings or money market account. Such accounts do not earn significant interest, but that is not their point. Instead, emergency funds allow you the flexibility to invest other money in necessarily higher risk ways. For example, you will likely purchase stocks or mutual funds as part of your retirement portfolio. If an emergency struck and you were forced to sell while the market was low to cover living expenses, you will have lost money.

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This is entirely avoidable. Emergency funds have the added benefit of helping you – and potentially a more risk-averse spouse/partner – sleep more comfortably, irrespective of how your money is otherwise allocated. Do not skip this step.

5.2 Debt

If you have consumer debt such as high-interest credit cards, pay them off immediately and plan on never carrying high-interest consumer debt again. Such debt is usually costly (due to high interest rates), not tax deductible, harmful to your credit rating, and ultimately the end result of spending more on a monthly basis than your income allows. The transition from residency/fellowship to attending is likely the only time in your career where you will see such a dramatic increase in your income. Using this income to pay off unhealthy debt before increasing your discretionary spending is an important first-step toward financial independence.

A full discussion of the pros and cons of auto loan and home mortgage debt is beyond the scope of this manual. However, it is important to remember that banks will commonly loan you more money than you should borrow, especially as a high-income earner. So how much should you borrow? A good starting point is to keep your debt-to-income ratio (calculated as the ratio of the total of your monthly loan payments to your gross monthly income) well below 1:3. Keeping a low debt-to-income ratio will, much like an emergency savings fund discussed above, provide a cushion of security in the event an unexpected expensive event occurs.

Student loan debt is largely unavoidable. American Association of Medical College (AAMC) data suggest that you may have upwards of $200,000 in education debt. A clear plan for paying this off should be a high priority. Broadly, there are two ways to do this. The first is to seek loan forgiveness. Many borrowers holding federally guaranteed loans are eligible for income-based repayment. If you made small payments on your loans during residency, it was likely through one of these programs. Payments made through such programs while employed by a non-profit institution (e.g., academic medical centers, VA, and other public hospitals) for 10 years may qualify you for a federal program known as Public Service Loan Forgiveness (PSLF). After 10 years of payments, the balance of your loans is forgiven. This program has some risk. While it may exist in its current form indefinitely, multiple recent federal

budgets have proposed sweeping changes. You may also choose partway through these 10 years to leave for a private employer. However, PSLF could also substantially reduce the amount of debt that you ultimately pay back. Consider a trainee who makes payments during 5-6 years of residency and 1-2 years of fellowship through one of the qualifying federal programs such as Pay As You Earn (PAYE). In a best-case scenario, these payments would be based on a relatively low trainee salary for 8 years and higher attending salary for 2 years. While you could begin making such payments even after training, this will expose a higher salary to the income-based repayment calculation.

Strategies exist to mitigate the effects of PSLF changing or ending if you do pursue this program. For example, you could set money aside in a personal “PSLF side fund” while making minimum payments. If the program ends prematurely, you could use this fund to pay off your loans. If your loans are forgiven, you’ll have a lump sum with which to invest. Whatever you choose, becoming an expert on student loan repayment options can save you thousands of dollars if you have large amounts of educational debt.

Second, and more reliably, you could just pay off the loans. You may choose to first refinance to secure a lower interest rate, for which you qualify now that you earn an attending salary. Quickly paying off your loans is one of the only forms of tax-free, guaranteed returns. Some argue that this is unwise because you could earn a higher rate by investing in the market. Why pay off $200,000 in debt at 5% interest if you could earn 10% by investing in stocks? These arguments are mathematically sound but ignore both market and behavioral risk. You will not earn greater than 5% on your money if the market drops, or if you forget to invest and instead buy yourself a new car. The freedom and peace of mind that result from eliminating debt are harder to quantify, but are also valuable. You may ultimately leverage this freedom to change jobs, work fewer hours, or otherwise improve your well-being in ways that you might not consider if still heavily in debt.

5.3 Retirement & Investing

Of all of your long-term financial goals, retirement is perhaps the most important because it is both inevitable and expensive. How much should you save? The answer is ultimately, “it depends.” Recognize that by virtue of starting your peak-

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earning years later in life than non-medical professionals, you have already fallen far behind. As a general rule, to eventually replace a reasonable fraction of your pre-retirement income, anticipate saving 20% of your gross attending salary each year for retirement alone. Begin this practice as early as possible, ideally during residency with a smaller amount. Not only will this establish a useful habit, but it will also ensure that you receive your employer’s retirement contribution match.

This money should preferentially be used for investments within tax-advantaged retirement accounts such as 401(k), 403(b), 457, IRA, Health Savings Account (HSA), and so forth. Each of these accounts has unique advantages that can help maximize the growth of your investments. For example, 401(k) (private, for-profit employers) and 403(b) (nonprofit and government employers) plans allow pre-tax contributions of up to $19,500 (for tax-year 2020). This money grows tax-deferred, enabling you to pay the income tax at the time of distribution (upon retirement at age 59.5 or older), at a rate which is likely to be a lower marginal rate compared to when the funds were initially earned. While uncertainties will always be present (future tax rates, inflation, status of the financial markets, etc.), failure to educate yourself about, or effectively utilize tax-advantaged retirement programs may cost you hundreds of thousands of dollars over the span of your career.

The good news is that investing is less complicated than many would have you believe. Once you understand the different types of programs and accounts that are available, all that is left is to purchase a combination of investments (e.g., stocks, bonds, and funds thereof) that match your goals and risk tolerance. Low cost, passively managed index funds such as Total Stock or Total Bond Market index funds are likely the best way to do this for most investors. This is particularly true for those saving for retirement who wish to simplify their portfolios. Target date funds or “lifecycle funds” are low-cost mutual funds that track stock and bond indices, changing the ratio of these assets to decrease risk as you approach retirement (i.e., the target date). If you do nothing more than invest 20% of your salary in such a fund from now on, you will be far ahead of many of your peers in retirement planning. It does not need to be more complicated. By modifying asset allocation, a similar strategy may be used to save for other long-term financial goals such as a home or your children’s college education.

Some argue that investing is too complicated for you to do on your own and that you should leave this to a financial professional. There are certainly benefits to this approach. If you are not willing to spend time educating yourself on personal finance and investing, or if the alternative is simply that you would not plan or invest, you will benefit immensely by paying someone else to do this for you. Just as importantly, a financial planner may help protect you from yourself. Whatever you pay in fees could pale in comparison to the losses you sustain if you panic and sell inappropriately during a market downturn.

However, recognize that even seemingly small investment management fees can have dramatic effects on your account balance over time. Consider two urologists, both earning $350k per year and saving 20% of their incomes in tax-advantaged retirement accounts. One has educated herself about personal finance and manages this money independently; she pays 0.2% annually in fees for index funds. The second pays 2% annually in fees to a financial planner to invest the money for him. Both portfolios grow at 7% per year. After 30 years, these accounts will hold $6.4M and $4.7M respectively, a difference of $1.7 million dollars, or 30%. What sounds like a small fee results in a very large difference in account balances over time. Moreover, by the time you have educated yourself sufficiently to judge the value of professional advice that you might purchase, you will likely know enough to invest the money yourself. One option to mitigate this effect is to pay a financial planner episodically on an hourly basis to re-evaluate your investment plan. Spending even $500-$2,000 for such advice could ensure that you are on track without resulting in a substantial drag on your annual investment returns.

5.4 Budgeting

It will be very difficult to meet any of the above goals without keeping a budget. Free or inexpensive software such as Mint (www.mint.com) or You Need A Budget (www.youneedabudget.com) are available online to help you track and plan your spending. You may think that your salary is so high that this is unnecessary, but you are wrong. Consider the countless stories of professional athletes making multiples of your salary who manage to declare bankruptcy. No matter how much you earn, it is always possible to spend more. If this idea is too daunting, start by just tracking your spending. Even this simple task will likely encourage you to save and spend more effectively. A common refrain is to “live like a resident” for a few years after training. If

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you can manage to avoid growing into your entire attending salary immediately, you will be able to use this money to pay down debt, save for retirement, fund a house down payment, or achieve any of the other major financial goals that you have likely been neglecting during residency. The other commonly used adage is to “pay yourself first.” This is the concept that you use automatic deposit/transfer processes to contribute to short, intermediate, and long-term savings and investment accounts. This ensures these accounts are appropriately funded before you have a chance to spend the money on discretionary items which have less long-term value (e.g., restaurants, clothing, recreation, etc.). Living by this mentality helps ensure you meet your longterm goals and simplifies your budget because if followed consistently, the money will have been deposited before it was even available to budget for discretionary use in the first place.

5.5 Insurance

Consider how life, disability and other insurance can impact your financial wellness.

Life

Life insurance should be the simplest insurance to buy because it is conceptually simple and for most young urologists, relatively inexpensive: if you die while you hold the policy, the insurance pays your beneficiaries a lump sum. That’s it. A typical policy features a 20 to 30-year term, meaning that the insurance company guarantees the payment over that time. You want this term because 20-30 years from now you will hopefully have saved enough money that your dependents would use that instead of your lost future income to support themselves should you die. If you reach this point of financial independence sooner, cancel the policy. In the meantime, opt for a term policy in the range of $2M - $5M. Another option is to “layer” multiple term policies (e.g., $1.5M 30 year term + $1M 20 year term + $500k 10 year term). This provides the greatest benefit when it is needed most (early in your career when you have little in your investment accounts and, if applicable, your children are likely still financially dependent on you), but saves on cost compared to a single high value, long-term policy.

commissions if they can convince you otherwise.Disability

Consider that you may have a 30-year career ahead of you. Not accounting for inflation or changes in reimbursement structure, this may amount to $10.5M of earning potential over the span of your career ($350k x 30 years). If you currently owned a fragile item worth $10M, would you not insure it? That’s what people without disability insurance are doing. Disability insurance is expensive because people frequently submit claims for these policies. Recall all of the patients that you have seen throughout your training with illness or injuries that restrict their ability to work. Now think of all of the ways that you depend on your health to optimally function as a urological surgeon: you must be able to think rapidly and clearly, have the stamina to stand for several hours at a time, and retain excellent gross and fine motor function. It is not difficult to imagine how a decline in any aspect of your health could restrict your ability to earn a high salary during your peak working years. High-quality disability insurance policies will protect you if this happens. You should look for an own-occupation, specialty-specific, individually owned disability insurance policy. Purchase this policy as soon as you can afford it – ideally in residency – or run the risk that new medical conditions you develop will be considered pre-existing and thus uninsurable.

Other

Review the coverage that you have selected on your existing insurance policies, including things like car, renter’s, or home. Now that you can more easily afford it, you may wish to increase the liability limits on these policies. Even if you currently have a negative net worth, your profession may make you a target for litigation. You should further expand coverage by opting for umbrella insurance that kicks in when an existing policy reaches its coverage limits. For example, consider a car insurance policy with a personal liability limit of $500k. A $5M umbrella policy would cover you for claims between $500k -$5M, even if such coverage is not offered by the car insurance company itself.

You should be wary of policies such as “whole Additionally, even large umbrella policies are life insurance,” which are sold under a variety of relatively inexpensive, given the very unlikely confusing names and seek to combine aspects of possibility of a claim under them. Importantly, insurance and investing. They are almost never umbrella insurance does not cover malpractice, the best option for either of these purposes so be sure to review these policies with your and are sold by agents who stand to earn high employer separately.

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