Jan 19, 2016 | Ravi Hira, MD and Payal Kohli, MD
Career Development

As we begin the new year and further explore the life-altering and career-changing decisions ahead of us, we wanted to share a few thoughts on the process of interviewing. None of us are new to the process; medical school, residency, and fellowship interviews were challenging but this may be the last set of interviews some of us will go through. Fortunately, on this occasion, travel costs are covered by the potential future employer and, for many of us, it may be the first time we feel "wanted".

1. Understand the Finances: Irrespective of the practice structure, ask to schedule a meeting with the administrator or practice manager who knows all about the dollars and cents. They will be the ones to discuss salary structure, bonus incentives and relative value units (RVU) targets. It's important to ask them about supplemental guarantees and options to switch to an RVU-based model, as these will change from one practice market to another. Setting up a practice in a metropolitan area usually takes two to three years, and you do not want to have a significant drop in income after your first year because the supplemental guarantee was in place for only the first year. It is also acceptable to ask to "see the books" to understand how the billing, collections and split occurs.
2. Meeting With Disgruntled Employees: One of my mentors had mentioned that going on job interviews was like going out on a date. Everyone gets dressed up, tries to look their best and is polite. It's only after you meet and hear about practices from former partners or unhappy partners that the truth begins to emerge. Perhaps the practice has two out of five high volume operators who have every intention of splitting call with the new hire, but no intention of sharing patients or economic productivity. The other three may also want to split call, but they may volunteer the difficulties they've had in building practices while competing with their partners. An ideal situation would be to share new consults and procedures equally among all partners, but this rarely occurs due to the economics of health care. However, in the grand scheme of things, teams usually win over individuals.
3. High Risk Procedures: For those doing procedures, another point to consider is what the practice has been doing with its higher risk procedures, such as chronic total occlusions, transcatheter aortic valve replacement (TAVR) and ventricular tachycardia ablation. For example, if you are an interventional cardiologist and have a patient with a chronic total occlusion, "where does this patient get revascularized" and "do I get to be the one doing the procedure" are questions you may want to ask. Similarly, you may want to be involved in procedures such as TAVR for your patients that are referred to a bigger center or hospital. It is also important to know the referral processes for cardiothoracic surgery and how risk averse the surgeons at your hospital are.
4. Stay Current: The field of cardiology is evolving rapidly, and it is becoming increasingly difficult to stay up to date with newer data, procedures and techniques that are available. While you may not be able to deliver many of these therapies in a smaller town or hospital, knowing the possible options and who to refer to is something to consider. Many practices and hospitals pile on pressure for RVU generation with little regard to quality of patient care being delivered. Asking about the processes for professional growth and development will give you an insight into the core principles and values of the practice. This is not just funds for continuing medical education credits but time away without RVU penalty for you to acquire and implement new skill sets.
5. Mentorship: This is by far the most important consideration at your interview. No matter what kind of practice or job you go to, the relationship you develop with your mentor coming out of fellowship (if you find a good one), is likely to last a lifetime. You will have very difficult situations over your first few years functioning as an independent cardiologist, and in my humble opinion, this is magnified several fold if you do invasive procedures. There is no attending to turn to when faced with challenging situations: you're it! It is critical to know and feel that someone at your new practice will "have your back" when things don't go well and will protect you from getting involved in high-risk situations. These are people who will pick up the phone when you call them at 3 a.m. and come in to the hospital and hold your hand through difficult situations. You will need at least one of these people available to you. I would think long and hard about taking any position without them.

These are questions which you should have answers to at the end of your interview day. This is not an exhaustive list and many other factors play a role in the decision making process. It is important to remember that unlike residency or fellowship, your job is not a time-limited endeavor. Your involvement in a practice may last from a few months to your entire career, and satisfaction and happiness are not mathematical equations based on dollars, RVUs, call frequency and vacation days.

This article is part of a series focused on career development for fellows in training (FITs), authored by Ravi Hira, MD, assistant professor in the division of cardiology at the University of Washington, Seattle, WA, and Payal Kohli, MD, an attending cardiologist at Kaiser Permanente in Denver, CO.