Career Advice for Newly Trained Electrophysiologists

The advice presented in this article is based upon my personal story and my observations of some of the dynamic changes occurring within our chosen profession. Between 2009 and 2010, I interviewed at 14 different locations across the United States looking at various opportunities, including three- to four-person cardiology groups in private practice in which the lead cardiologist’s wife was the practice manager (a tricky situation), to large 40- to 50-person cardiology groups in which I was the fourth electrophysiologist, to becoming employed by a hospital system.

I was in private practice for eight months on a partnership track prior to becoming an employed electrophysiologist by a hospital.

I have had the good fortune of needing to hire a second electrophysiologist and was privileged to interview five top-notch EP candidates. Having been through the job search process during these recent times and then helping to recruit a new electrophysiologist, I offer my advice and thoughts here. The practice of electrophysiology is fantastic, alive, and ever changing; I hope this article helps provide perspective as you start your career.

General Outlook

Electrophysiology is the fastest-growing subspecialty within cardiology.¹ In 2009, the Heart Rhythm Society (HRS) conducted a comprehensive survey to assess changes in the field of electrophysiology since 2001.² The survey identified economic trends that will have a significant impact on the EP workforce in the coming years, including healthcare reform and the aging patient population.

According to the American Board of Internal Medicine (ABIM), in 2011 there were 1,922 certified clinical electrophysiologists in the United States.³ The number of certified EPs has risen since 2008,⁴ although it is estimated that only 90 trained EPs enter the workforce annually.¹ There is an average of one EP for every 127,500 people in the US,² and they are not distributed evenly across the nation. Furthermore, of physicians over 60 years of age, 23% are expected to retire in the next five years.²

It is clear to see that market forces are aligning to ensure long-term growth of electrophysiology for years to come. In fact, forecasting companies predict a solid decade of growth ahead for electrophysiology.

However, please do not come away with the expectation that when you leave training that simply setting up shop and applying for privileges at a hospital will guarantee a steady flow of patients. One needs to understand that there are fundamental changes occurring with the practice of medicine that have the potential to change referral patterns and prevent one from participating in the projected growth for electrophysiology.

Changes in Health Care and its Impact on Private Practice

In 2010, Congress passed the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act, which together represent the largest change to affect hospital finances since 1983.⁵ In a survey conducted by The Physicians Foundation in 2010, 67% of physicians had a negative reaction to the passage of these reforms. Health care reform is expected to add 16 million people to Medicaid, while at the same time approximately 75 million baby boomers will begin to qualify for Medicare benefits.⁶ Responding physicians of the HRS survey (2009) indicated a median work week already at 60 hours, but anticipate their work volume increasing to meet the growing demand for specialty services.²

These reforms will have compelled more physicians to consolidate with other practitioners or become hospital employees.⁶ Eighty-nine percent of the physicians of The Physicians Foundation survey believe the traditional model of independent private practice is on the decline.⁶ They believe patient loads will increase while private practice becomes less viable due to rising billing service costs, higher malpractice insurance premiums, reduced payments for some in-office procedures,⁷ and reductions in Medicare reimbursements.

Herein lies the challenge: a newly trained electrophysiologist entering the job force has several choices. He or she can become employed by a hospital system, a large private practice cardiology group or multispecialty group, or join with another EP exclusive group. Irrespective of which scenario one chooses, let’s look at each scenario and analyze some of the pros and cons in the context of the current healthcare changes.

Joining with a large private practice cardiology group or multispecialty group certainly gives one an opportunity to advance on a partnership track as well as the opportunity of ownership of a business model. There is always a sense of pride in ownership. Furthermore, if you are the only EP for the practice, you would have a captured market in terms of patient referrals. However, with increasing practice administrative costs and decreasing reimbursements, many practices are having difficulty remaining financially solvent. Some practices are recruiting EPs without informing them that they are also entering into negotiations with hospital systems. Furthermore, in the past three or four years, I have seen a palpable rise in instances regarding newly hired EPs joining cardiology groups only to find that their contract was cancelled or being renegotiated due to negotiations occurring between the cardiology practice and a hospital system. My advice for this scenario is to inquire whether or not the group is actively engaged in negotiations with a hospital system. The reality is that greater than 50% of private practice cardiology groups have entered into negotiations, and the other 50% have at least thought of the prospect. In addition, you have to inquire how your contract would be affected if the group were to become employed. Typical concerns and issues that will arise from this scenario include acquisition of practice assets, transitioning to an RVU (relative value unit) based income versus collections model, and assuring that the billing practices of the hospital entity are collecting accounts receivable appropriately. If you are a newcomer to the practice, you likely have no vested interest in monies transacted to acquire a practice’s assets, which is entirely fair. However, you have every right to insist that your employment contract be at an equal playing field with the remainder of the group. Remember, as an electrophysiologist, your asset revolves around the fact that the hospital systems derive revenues from the procedural work you perform in the EP lab and ancillary preprocedural testing that may be performed.

If you are fortunate enough to find a group that has no intention of joining with a hospital system, it is likely for one of a few basic reasons: 1) They are located in a geographically underserved area and have favorable reimbursement contracts and minimal competition; 2) They have been judicious and fiscally responsible in the management of their practice overhead (understand that many other practices may have been fiscally responsible, but still chose to merge with a hospital due to rising costs and declining reimbursements); 3) They have joined with an ACO (accountable care organization) or CIN (Clinically Integrated Network) formed of physician members only. Irrespective of the reasons, it is critical to analyze where your patients will come from and if there are any threats to your referral source being eroded.

Becoming a hospital-employed electrophysiologist is another viable alternative for job opportunity, so long as you understand the source of your referrals. For illustrative purposes, there was a job opportunity in California where a single hospital system offered a three-year salary guarantee plus cost defrayment for building office infrastructure and hiring of support staff. Their base of cardiac patients came from private practice cardiologists, some of whom had exclusive HMO contracts over several thousands of patients. Upon further investigation, it was apparent that the cardiologists were loyal about sending their patients to this hospital. Furthermore, the hospital administration did a good job of maintaining an atmosphere of trust among their physicians, and many of the private practitioners held various committee leadership roles. It was readily apparent that an independent EP doctor could become employed in this environment and build a successful practice with a reasonable expectation that patients would be sent to his employing hospital. As it turned out, a colleague accepted the job and is excelling for the reasons listed.

Typically, hospital-backed employment opportunities offer better salary guarantees. Additionally, hospital employment opportunities have resources that typically are not available with private practice opportunities. For example, most hospitals have access to media departments and public relations that can help you raise public awareness of your practice at no cost to you. Most hospitals typically have better negotiated reimbursement rates for various insurance providers and handle renegotiating various insurance contracts as they annualize. Finally, as more cardiology practices join a hospital employment opportunity, it provides immediate growth opportunities for the EP.

Joining an EP-exclusive group is a final employment scenario to consider. The typical EP-exclusive group will have several venues of referral sources that in their own right diversify the patient referral stream. However, this also means that you may have to potentially drive from one hospital system to another, which can lead to inefficient time utilization. EP-exclusive practices give a virtual guarantee that one will only be practicing electrophysiology. However, like with the above-mentioned opportunities, one has to analyze the referral stream. Does the EP group have a closed contract with their EP laboratory where they are the only EP provider? It is not necessary, and in fact, typically not common. But, if they do have an exclusive contract, similar to radiologists or ER doctors, this can be a beneficial scenario to consider. Where are their referral lines coming from? Are they drawing referrals from cardiology groups that are now considering employment opportunities with hospitals? If so, there may be a fundamental change in the referral stream. EP-exclusive practices are getting more difficult to maintain with increasing national pressures on cardiology groups to join part of a healthcare entity. Those EP-exclusive groups who can maintain a successful affiliation within a physician-only ACO or CIN may fare better during all the changes going on within the healthcare environment.     

Where to Find the Jobs

Networking will be your most productive and cost-effective asset. Contact colleagues from your training program who have recently entered the job market ahead of you. Making those around you aware of your interests and availability will pay dividends in the long run. Look at the job opportunities listed on the Heart Rhythm Society website as well as through EP Lab Digest^®.

It is also worthwhile to contact physician recruitment firms and representatives of device-based companies. Frequently, the device-based companies carry their own internal list of various geographic opportunities for electrophysiology services. Cold calling hospitals can also be another option, but it is strictly a numbers game unless you have insider information that the hospital is actively recruiting an electrophysiologist. Restrict your cold calls to only those hospitals or institutions which you are serious about pursuing.

Electrophysiology program directors are often sent job listings and are aware of jobs in their immediate vicinity. They would also be able to guide you on internal employment opportunities with your training institution.

There are several key ingredients that make for the ideal job opportunity. Most of all, it is important to be flexible — 65% of physicians in the HRS survey (2009) have made geographic changes since completion of training. EP jobs are clustered in high-population areas, and it is easier to move earlier in the career.

The Art of the Interview Process

The greatest challenge of the interview process may simply be setting aside time from a rigorous training schedule to interview. It is customary for the interviewer to handle the reasonable expenses associated with the interviewee. Typically, we are looking for a candidate who possesses sufficient technical skills to be an asset to the practice and not a liability. This is vetted by simply talking with a candidate’s program director and various lab staff. Don’t forget that we have the ability to inquire about a candidate’s reputation through the device industry. Remember, when a practitioner refers a patient to you, you are a reflection of the practitioner, and that relation is sacrosanct and should be upheld.

From the interviewee’s perspective, pay particular attention to how members of your potential job opportunity interact with one another. Is there genuine camaraderie, or is there a palpable discord within the group? Are you the only young recruit, or are all of your potential new partners over the age of 60? If so, they may be looking to hire you but not be serious about your career advancement. Be careful about those practices who entice you by stating that they are approaching retirement and are looking for someone to gradually ease into their practice. If they are not willing to guarantee this transition in writing, then look elsewhere. Be wary of groups who are not willing to clearly define the “buy-in” process if you are on a partnership track. If looking at a hospital-based position, have you been introduced to the cardiologists/internists who would be serving as your potential referral stream, or have you only been introduced to hospital administration members? If joining a private practice group, have you been given an opportunity to meet all the members of the practice? Frequently, a practice may purposely not want you to meet a particular physician member due to their contrary disposition. If that is the case, you should make a special effort to meet this person to assess the situation for yourself prior to making an important decision. If you get the runaround, simply tell the practice manager you did not have the opportunity to talk with Dr. X and it would not be fair to not introduce yourself to this physician. Frequently, you may need more than one visit for the job opportunity you are truly serious about. Make sure your significant other approves of the job location. Also, communicate your career interests; do you want to pursue EP only or a blend of general cardiology and electrophysiology?

As a young professional, it is important to show others that you are a hard worker. Sometimes that means you are the first one in and the last one out. Advancements in technology progress fast — be sure to stay up to date in the field.

Contractual Considerations and Miscellaneous

Most new electrophysiologists out of training are concerned about their employment salary. Rightfully so, after having spent about 30 years in training and accumulating debt, you have every right to be concerned about this matter. The average salary ranges in today’s market goes from $275,000 to greater than $500,000, depending on geographic location and market density of EPs. The more saturated the market is and the more desirable a geographic location, the lower the starting salary. How much you can negotiate truly depends on what you have to offer. A freshly trained EP doctor may not have as much to offer to a hospital system as one who has been in practice for five years. Nevertheless, the odds are on your side that there are more hospitals and groups that need EP services than there are EPs to fill the slots. The trick is being able to find job opportunities, because there is no one centralized hub with all the EP jobs posted for review.

Besides salary, make sure that the necessary ingredients for a prosperous and long-lasting career are present. These ingredients include making sure there are at least eight to ten cardiologists who can serve as a legitimate referral base, ensuring that the administration of the hospital is committed to investing capital into the electrophysiology lab in terms of capital expenses and advertising, and ensuring that adequate and competent staff are present to help you run the electrophysiology lab. If you can identify these components for a job opportunity, then you are already ahead of the curve. More importantly, there will be unexpected changes along your career, and it would be better to weather these changes with a strong foundation.

From a contractual standpoint, my biggest advice is to hire an experienced health care attorney to review your contract. They may even act as a negotiator on your behalf if you are willing to pay the price. When hiring an attorney, get them to commit to a flat fee; otherwise, you may find yourself paying for more billable hours than anticipated.

Conclusion

The field of electrophysiology is ever growing and changing. Now is an exciting time to be a practitioner of the art. Hopefully, by providing insight into some of the contemporary issues affecting the field, one will be better equipped to take on the next step in career growth.

Acknowledgement. Dr. Anand would like to acknowledge Ms. Tiffany Hunt for her assistance in manuscript preparation.

References

1. Estialbo A. Is EP’s success its own problem? An update on EP physician recruitment. EP Lab Digest 2010;10:1–11.
2. Deering TF, Clair WK, Delaughter MC, et al. A Heart Rhythm Society Electrophysiology Workforce study: Current survey analysis of physician workforce trends. Heart Rhythm 2010;7:1346–1355.
3. ABIM.org. Feb 17, 2011.
4. Rodgers GP, Conti JB, Feinstein JA, et al. ACC 2009 survey results and recommendations: Addressing the cardiology workforce crisis. A report of the ACC board of trustees workforce task force. J Am Coll Cardiol 2009;54:1195–1208.
5. DiNardo C. Managing the impact of health care reform. Cath Lab Digest 2010:34–36.
6. The Physicians Foundation. Health Reform and the Decline of Physician Private Practice. October 2010. <Health Reform and the Decline of Physician Private Practice.pdf> Accessed 12 Feb. 2012.
7. Wann S, Jaskie S. Health care reform and the community cardiologist: 2010 and beyond. Cardiology Today July 2010. Accessed 12 Feb. 2012.