A. PRACTICING IN A COMPETITIVE MARKET

more often it is realized slowly, after years of interests and career goals not aligning to what the job offers. A change in leadership or department structure that significantly alters the job may also cause an early-career urologist to reflect on whether their current position is a good fit. Changing jobs is a BIG DEAL and is often cited as one of life’s major events that can trigger significant stress. Therefore, evaluating both external factors as well as your internal mindset is critical before making such a decision; it’s important to remember that there are challenges with any job and that no job is perfect. As you reflect on whether or not to pursue a new position, do your best to be as effective as possible in your current position. This initiative will serve to help you grow a practice and build a reputation, preparing you for future opportunities. Develop your niche. Even if you are not destined to remain at your current job much longer, it’s important to remember that one is often hired based on performance and accomplishments attained in a previous position. The process of transitioning to a new job can be arduous and take several months. As such, if your current position no longer best serves your career goals and/or aligns with your core set of values, understand that looking for a new position is likely going to be a long term undertaking. Consider beginning this undertaking by reaching out to colleagues within your subspecialty society or practices in your area of interest with discreet inquiries about potential opportunities. Recognize, however, that no inquiry is absolutely discreet. Ideally, your job search should target positions that offer a promotion from your current role (e.g., from assistant to associate professor). You should also be keenly aware of exactly what you’re looking for in a new position that your current position doesn’t or cannot offer. For example, if your current position requires PA support and it is unable to be provided, inquire about support available when interviewing for new positons. Some important factors to consider when evaluating a new position include the following: 1. Remember, there are “pushes” and “pulls” when determining whether or not to pursue a new job. While you may identify a “push” in your current role that is causing you to look for a new position, be sure you aren’t leaving one non-ideal situation for another. Instead, look for a job that “pulls” you in (i.e., is more ideally aligned with your clinical and research interests, better fits your short- and long-term plans, offers more support related to your ultimate career goals, etc.). 2. Understand your current contract. Provisions that should be considered when separating from an institution or practice include (but are not limited to): terms of separation and timing, restrictive covenant, non-compete and scope and tail malpractice coverage. Consult an attorney to review your current contract before making any decisions, as a breach of contract can have serious financial and professional repercussions. 3. Ensure you compare “apples to apples.” A good salary in a low cost of living location may be a better fit than a great salary in a high cost of living location. Translate compensation to quality of life for a fair comparison. In addition, be sure to evaluate the benefits package at your current position to ensure you’re able to accurately compare with a new offer. 4. Recognize that some AUA committee and leadership roles are appointed by AUA Section leadership. If you currently serve on an AUA committee, ensure you have a full understanding of the implications a geographic move could have on the role. 5. Always leave on good terms. Urology is a small world, and you never know when you may need to reach out to former colleagues within your subspecialty society or AUA Section in the future. 6. Don’t bad-mouth your former boss or colleagues.

When discussing your decision to move on, a simple and concise statement such as, “I’m leaving for a different opportunity” should suffice. After accepting a new position, the routine of a new job will quickly take over and once you settle in, your old job becomes a chapter in your career that has come and gone. Hopefully, you were able to take full advantage of that chapter and if not, be sure to take the next opportunity to “build it bigger and better.”

WATCH: Kirsten Greene, MD, discusses early-career job change as part of the 2020 AUA Young Urologists Live webinar. APPENDIX A: PRACTICING IN A COMPETITIVE MARKET

Competitive job markets are typically located in areas with high desirability – often, a major metropolitan area with appealing amenities and a well-diversified economy. Who doesn’t want to live in a major metropolitan area like New York City, Los Angeles, Houston or Boston?

Okay, of course the metropolitan lifestyle doesn’t appeal to everyone. But living in a major metropolitan area does offer many unique advantages: easy access to arts and culture, lively and diverse social scenes, diverse selections of dining, ease of national and international travel, etc. If city life is up your alley, you are not alone – which can make seeking jobs in such a market extremely competitive and present a set of unique challenges when looking for your first job. Consider some of the information below if you think practicing in a competitive market is right for you.

A.1 Start Your Networking Now

If you’ve already identified a specific metropolitan area you’d like to practice in, consider applying to complete some of your training there. Being a resident or a fellow in the city you want to ultimately practice in can increase your chances of hearing about positions that aren’t always formally advertised. Using your network of colleagues, friends and family can be very important when looking to secure a job in a competitive market. Having an “in” can provide you with sometimes difficult-to-find information on compensation, group culture, and what you might expect regarding patient load, case mix, etc. Leverage relationships you have from childhood, college, medical school and residency – tapping into your network can give you an edge on the competition. Consider the following if you were unable to train in the city you want to practice in and don’t have an “in:” • Reach out to academic departments, hospitals, and large urology group practices in the area to offer Grand Rounds presentations. • Get involved at AUA Section meetings or regional conferences in your desired location.

Often, such meetings (e.g., New York Section of the AUA or the Philadelphia Urological Society) are small, intimate meetings that may allow you to connect with potential employers.

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A.2 Be Adaptable

Plans to be the robotics expert in the big city where there are already thirty experts in the area may not pan out. Consider some compromise. Are you open to researching an unmet need and then providing it in the big city? As it relates to case mix and practice building, be open to taking advantage of any needs you see in the group or market – perhaps the group has a need for an expert in minimally invasive BPH surgery, or the market has a need for a prosthetic urologist. Don’t be afraid to reinvent yourself to accommodate; this could just be the “edge” you need to gain a foothold in the market (many experienced urologists will tell you that their “niche” came from somewhat random circumstances!). As with any job, there will be growing pains. In the first few years, many young urologists in competitive markets may feel alone in facing the challenges of early practice. Be purposeful about meeting other urologists in the area – even those in “competing”

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groups. They are going through much of the same experiences you are, and you may end up working with them one day! Plus, as you build your niche, you will want to have contacts who trust you and send you challenging cases.

A.3 Cost of Living Considerations

Living in a non-competitive market can often offer a urologist a higher salary with a lower cost of living. Competitive markets, however, can be just the opposite. Competitive markets tend to have a high cost of living – combined with lower compensation, this can have a significant impact on lifestyle. Housing costs are the largest expense for most people in the early stages of their career, and urologists are no different. Frugality in a house can go a long way – renting for 1-2 years can be a good move in a competitive market to allow savings for a down payment and avoid “locking in” to a situation that could turn out to be a poor fit. “Hitting it big” in the big city doesn’t happen often. Sure, if you open up the right office for the right disease at the right time with the right reputation, you could earn much more than standard rate for your profession. But don’t count on it. It’s much more realistic to plan on living within your means and understand that the desirability of a metropolitan area can come with some costs.

A.4 Initial Negotiation and Non-Compete

In a competitive market, applicants have less negotiating power when it comes to important factors such as compensation, case mix and allocation of resources. Do your research on compensation in your desired specific market for a realistic idea of what is reasonable. Realize that starting salaries tend to be lower. Often, hospital employed groups and large private practice groups use physician compensation calculators, such as the MGMA, AAMC, etc. The type of practice you may want to initially develop may also be less negotiable. Many metropolitan areas are populated with wellestablished urologists, so it may take several years to build a “niche” practice in areas like robotics, reconstructive surgery, female pelvic medicine or complex stone disease. Non-compete clauses bear special mention in competitive markets. If you are taking a job with location as the leading (or one of the leading) factor, chances are you’re probably looking to stay in that location for a substantial amount of time. Overly restrictive non-compete clauses (e.g., clauses that include long periods of time or large geographic areas) could present a big problem if you are dissatisfied with your job. Sometimes, a non-compete clause is very negotiable – other times, especially if you are looking to work for a big system, it may not be negotiable at all. Again, do your research on what is reasonable, and carefully consider the potential future impact of the clause before you agree to the job. Oftentimes, a non-compete clause has a washout period, so if you’re willing to move out of the area, consider a job in the suburbs or doing locum tenens for a year. Sometimes, if you have a desirable enough reputation or skill-set, the competing hospital may buy out your non-compete.

A.5 Stay True to Yourself

While competitive markets tend to give the applicant less negotiating power in general, do not let your desire to live in a certain area or take a certain job blind you to an overly negative situation. Even in an ideal location, enough negative work-related factors will lead to dissatisfaction. Try to find the right balance – reasonable pay in an established group with senior partners who take a sincere interest in mentorship and practice development for younger physicians. Do your due diligence on physicians who have left the practice – a pattern of younger physicians leaving the group within the first few years of practice can be a red flag.

A.6 Conclusion

While entering a competitive market is not for everyone, jobs in competitive markets may be the only realistic option for some young urologists due to family/spousal concerns, geographical preference and/or cultural factors. Setting yourself up for such a job includes exposure that allows access to a job, knowing your core set of values while remaining adaptable and being able to navigate the finances associated with working and living in a big city. Using your network and keeping your eye on longterm goals, in combination with a good dose of patience and a willingness to “pay your dues,” will be assets in the process. Good luck!

WATCH: Art Rastinehad, DO, discusses practicing in a competitive market as part of the 2020 AUA Young Urologists Live webinar.