Doctors in the last year of their cardiology training find themselves dealing with one of the most important dilemmas of their medical career: What's next? There is no single perfect answer to that question. Some may be happy joining a private practice in rural Pennsylvania and miserable being an academic cardiologist in Manhattan, or the other way around. There is one condition, though, that all graduating cardiologists are looking for: a good starting salary.

And why wouldn't they? Studying medicine is not cheap: In 2013, annual tuition and fees at public medical schools ranged from $31,783 to $55,294 and at private schools from $52,093 to $50,476. These figures do not include health insurance, housing or living expenses, and it is not a surprise that in 2013 the median debt for graduating students was $175,000. However, young graduates all hope that medical education is an investment that will eventually pay off: cardiologists are the second-highest-ranked specialty with a mean income of $357,000 (following only the orthopedists that average $405,000 in annual compensation). Moreover, about 23 percent of cardiologists earn $500,000 or more and only 8percent earn $100,000 or less.

When applying for your first job as a cardiology attending, it is important to know that hospital jobs can be tough to come by, and it is very much a matter of being at the right place at the right time. The early selection of the target geographic area and the desired work setting (academics vs. private practice) are key factors in getting the best job possible. Furthermore, both factors may significantly affect a cardiologist's compensation: physicians in the northwest region earned a mean of $403,000 in 2012, 30 percent more than their colleagues in the northeast, with the lowest compensation (a mean of $311,000 in 2012). As per Medscape's 2012 Compensation Report, cardiologists in single-specialty group practices are the top earners by work setting, with a mean income of $410,000. Private cardiologists working in hospitals earned a mean of $314,000 in 2012 as compared to cardiologists in academic settings that were at the bottom of the pack in 2012, with $230,000. But many cardiologists view the academic career as an opportunity to also be involved in research, teaching and education. Moreover, academic hospitals tend to have more organized infrastructure and are likely to have better benefits. Human resource departments are more likely to offer maternity or paternity leave, and links to other large hospitals, especially if associated with a large network, could come in handy if considering a move.

Graduating cardiologists in their busy schedules often tend to forget that developing a wide net of contacts during their fellowship may be crucial in landing a good job. Networking with people in the cardiology program and colleagues at cardiology conferences is an obvious strategy, but sometimes job information could come from sources you might not expect. These job sources include fellows and colleagues at other institutions, pharmacology and device company representatives, nurses and staff members that work or moonlight in different hospitals. Of course, supervising attendings, directors of fellowship and division chiefs can be instrumental in assisting with finding a position in a particular region and specialty.

Nevertheless, there are also many other ways to identify job openings, like in special sections of journals such as the New England Journal of Medicine, the Journal of the American Medical Association and the Journal of the American College of Cardiology. Other jobs are posted on the Internet, such as Medscape, the Medical Group Management Association, the American College of Phycisians or in the Society of Cardiovascular Interventions (SCAI) Fellow in Training Portal. Finally, there are several free placement services that assist physicians with finding and choosing among a number of practices like Practicelink or DocCafé.

The best advice is to start planning early, even before the final year of the fellowship starts. When geographic location is an absolute priority, then good networking in the local community makes you a very attractive candidate to nearby hospitals. Family ties in the area of employment are also important because it usually indicates an intent to stay at that job for a long time. If compensation is a priority, then approaching the various specialty group practices may be the preferred strategy. On the other hand, if the academic career is being sought, then involvement in research, funding, teaching and presentations at national conferences during fellowship will give the candidate an opportunity to network with those in academic cardiology.

Once the right job is identified, different issues arise: if the job is in the private sector, the business arrangements of the practice, the coverage and the conditions for partnership are factors that need to be examined. If the job is in academia, protected time and research funding become very important. When a contract is offered, remember there is always room for some negotiation. It is usually a good idea to have an attorney review the contract and to make sure you understand all the terms and conditions before signing it. Once the contract is signed, it's time to relax and enjoy your first real job; you have definitely earned it!

This article was authored by Konstantinos Charitakis, MD, FACC, in the division of cardiology at the University of Texas Medical School in Houston, TX, and the Memorial Hermann Hospital in Houston.