Since acceptance to medical school, we have been groomed to become cardiovascular specialists. Throughout internal medicine residency, cardiology fellowship, and additional time devoted to cardiovascular research, we honed our clinical acumen, medical knowledge, and procedural skills. Despite all of our medical training, the majority of fellows in cardiology are unprepared to understand the complexities and subtleties of contract negotiation and business management. How has over a decade of formal training not prepared us for the finale?

Many of us have a romantic notion of finding a permanent position and planting roots for our families. However, the reality is that many cardiologists seek new employment shortly after fellowship. Much of this may be derived from not knowing what to look for when looking for a job. It is through experience that we learn, and the role of mentorship should encompass not only education regarding medical care but also education regarding our rapidly evolving health care system. Additionally, job hunting can be challenging because many jobs are not advertised online or in journals, but rather require “knowing people” to get your foot in the door. This is also compounded by navigating the complexities of different practice models of the current era and seeing the impact of Centers for Medicare and Medicaid Services cuts, revenue generation, decreasing percutaneous coronary intervention volumes, and marked reduction in federal research, much of which we are shielded from during our training. Furthermore, without exposure to the available types of positions, it is challenging to know whether you would prefer to be in a small private practice group, large private group, or hospital employed group or attempt to obtain an academic position. It is also critical to recognize that the expectations of these different practice models can be vastly different.

Unfortunately, finding a practice is only the beginning of our education. Not surprisingly, the wording of the employment contract is completely foreign and filled with vague sentences certain to induce anxiety. In which class did we learn how to negotiate salary, benefits, money for continuing medical education, relocation expenses, and call schedule. In which lecture series did we learn about non-compete clauses, malpractice insurance type, the importance of “tail” coverage, practice structures, and partnership track. We learned to be proactive and ask questions that seemed, in the beginning, perhaps uncomfortable or not appropriate. “Why are you hiring?”; “Did someone leave?”, if so “Why?”; “Can I contact that person?”; “How long has each associate and/or partner been employed?”; “What is your governance structure?”

This is not another fellowship interview, but rather a pivotal point in our careers, and transparency is necessary. After wrestling with these issues on our own, we found advice and answers to our questions from those who have been our advocates from the start of our training, our mentors.

The job search began like a romantic story but rapidly evolved into a crude reality for which we are unprepared. Business is business; academic jobs are few and far between; and the face of private practice has changed. Health care is evolving, and for better or for worse, this is the environment in which new cardiologists will begin their careers. We would like to impart a few points that we picked up during this process to our co-fellows beginning this process across the country.

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  More than ever you will need mentorship. Look to them for advice early and often.

  
  
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  Before you interview, make a list of what you consider negotiable and what you consider to be a deal breaker, and stick to it.

  
  
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  Interviewing for permanent employment is different than fellowship. Be prepared to ask “sensitive” questions. Don’t ask what the group is looking for, rather tell them, honestly, what you are capable of and your career plans and let them decide if the fit is good.

  
  
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  Understand your salary structure. Is it based solely on productivity (revenue minus cost) or is it a pay-for-performance/value-based compensation (compensated by meeting pre-specified quality metrics). What is the bonus structure?

  
  
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  Make sure you understand the governance structure of the practice.

  
  
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  Take advantage of fellows’ courses focusing on life after training and how to interview.

  
  
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  Who you know often gets you an interview, what you know gets you the job.

Despite years of intense medical training, spanning a multitude of topics, the business of medicine and education regarding contract negotiation are completely absent in our training. Cardiology fellows are reliant on their colleagues and mentors to guide them. Much of what we as fellows learned was through mentorship and experience, but it seems that more formal talks by cardiology faculty at training programs may help impart this valuable experience. Perhaps a comprehensive education during fellowship, including education regarding the basics of business and what is important to look for within a contract, would help better prepare the next generations of cardiologists for the rapidly evolving field of medicine in these challenging fiscal times.