First and Third: One World Serious Health View

“Don’t go walking around like you just hit a triple – when you were born on third base.”

- unknown

“He wants to know why your skin is white and his is black,” clarified my translator. The Tanzanian boy, about 10 years old, was pointing to the skin on his hand and then to mine. His question in this remote kijiji (Swahili for village) was as arresting and profound as the inequities in global health.

My global interdisciplinary health team was in Africa as part of a feasibility assessment in partnership with a Tanzanian team to determine how to improve health in the region near Lake Tanganyika, which borders western Tanzania. While Tanzania is considered a low-resource, less developed country, the western region is considered the least developed area within this ‘third world’ country.

The local team was dedicated and committed to make a difference in the health of the people in the region. They believed that they needed a hospital and many clinics to do this since they knew that my colleagues and I had led hospitals and clinics in the U.S. and in eastern Tanzania. But my team was convinced that exporting the U.S. acute care model was not going to help them improve health, at least not nearly as much as investing the few available resources in other more impactful social determinants of their health. In addition, the local team did not have the resources, expertise or mission to expand the existing healthcare system.

First world population health is not an effective solution for Third world health challenges. First world population health efforts are often supported on the back of an acute care funding chassis: a hospital or healthcare system with access to a reimbursement system to sustain it. By design and nature, first world population health is typically incremental: icing on the core fee-for-service reimbursement cake.

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Your People Are the Key to a Successful System Transition

With an unprecedented number of healthcare provider mergers and acquisitions in recent years and new requirements being ushered in with the Affordable Care Act, healthcare professionals are in a constant state of technology systems transition. Though replacing a legacy system can be necessary and even beneficial to patient care or a hospital’s bottom line, times of transition deeply impact the people these organizations are relying on to provide quality care and keep the healthcare organization running efficiently.

To consider the implementation of a new system a success, you need to do more than make it to launch day on time and under budget. Your employees—the intended users of the new technology—need to understand the “why” behind the switch and actually use the system as intended with their sanity intact. In my experience, this can only be accomplished by engaging your people and giving them a voice at every step in the process.

Preparation

Before selecting a new system for your hospital or healthcare organization, it is essential to get the right people at the table to create a roadmap for the transition process. Be sure to involve and gather feedback from:

  • Employees who can think critically about workflow efficiencies so you can ensure that you aren’t carrying bad practices forward with the new system.
  • People who are highly knowledgeable about the current technology in place and its limitations. They will have invaluable insights into problems that any future systems need to solve.
  • Anyone who has a vested interest in the new system. If the new technology is clinical in nature, you need to make sure physicians and nurses have a voice. If it’s a change in back-office technology, human resources professionals or accountants who will use this technology regularly will need to be invited into the conversation.
  • Any department who will deal with a heavier-than-normal workload during the parallel running process or launch.

These groups have the expertise and high levels of investment to help your executive team document your current process, find the right technology to replace your legacy system, determine real costs, and set a reasonable timeline.

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Building Trust to Succeed

When it comes to building a strong leadership team, choosing top talent isn’t the only priority; building a culture of trust is also essential to growth and success. According to a recent PwC survey of more than 1,400 CEOs worldwide, more than half of organizational leaders believe a lack of trust is a serious threat to the success of their teams and their business. However, if you are aware of the importance of trust, and actively working to make it part of your workplace culture, you can use it as an asset to your organizational function, rather than a liability.

Environments where trust is a key component encourage innovation, increase the pace of decision making, and often team members outpace their competition. The Workplace Therapist Brandon Smith insists, “Trust enables teams to not just take risks but also to move more quickly. There’s little second-guessing in high trust environments because team members assume there’s positive intent.”

It’s hard for teams to move forward effectively if they don’t trust each another. Instead of innovating, they are second-guessing each other, unnecessarily reworking tasks, or relying on one or two key team members to get the work done. I have found that when you have trust, things move much more efficiently. You have the ability to take the risk because your team feels comfortable and supported.

Trust is key, and risk, innovation, growth, and expansion can only happen when you have a solid foundation of trust to build upon.

To maximize your organizational potential and lead in your sector and community, you have to create a climate of trust and transparency.

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Bridging the Gap Between Providers and Payers

Cheryl, a patient of a large, multi-city health system, received a call from her insurance company. Looking at Cheryl’s medical history, you’ll find her Type 2 diabetes is well-managed with oral medications. She sees her endocrinologist every six months to monitor her blood glucose and lipid profiles.

One day she received a phone call from her health insurance provider indicating that she could save substantially on her insurance copay by switching one of her daily medications. In the same week, she received a phone call from the local pharmacist who said the insurance company had contacted him asking he suggest changing this same medication.

Cheryl was frustrated and confused by the conversations because she adheres to her doctor’s care plan, and her diabetes is well-maintained. At each appointment, the endocrinologist indicates there is no reason to change any of her medications.

So, at her next appointment with this doctor, she mentioned both phone calls. After discussing the suggestion, her doctor indicates he doesn’t see a need to change medications if the current medication is not creating a financial burden on Cheryl.

In the end, Cheryl is pleased with the care she receives from her doctor, trusting his judgment and knowledge of the care she needs. However, she’s frustrated by the insurance company’s persistence in wanting her to change medications (because this wasn’t the first time they called about it) and drawing her pharmacist into the conversation to attempt persuading her. She assumes the insurance company is motivated by the financial gains they can make with the pharmaceutical companies, which then trickles down to the local pharmacy.

And, her perception is her reality, correct or not: Her doctor cares about her health, and the insurance company cares about money.

Just like Cheryl’s reality, here are some perceptions that the general population may have that can be overcome through the intentional and conscientious approach to care.

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Community Vitality: The importance of access to high-quality healthcare and K-12 education

The question of why some communities and companies grow and prosper, while others shrink or even cease to exist, has intrigued me for decades. Theories exist with no single one applicable to every situation. Two variables stand out to me as “must-haves” to ensure community vitality.

  1. Access to high-quality healthcare, and
  2. Access to high-quality K-12 education

As a registered nurse I have focused on the delivery of and access to high quality healthcare for the last 28 years. Having cared for patients at critical times in their lives, I have consistently seen how reliable access to affordable, preventive and restorative healthcare services is critical to community health, especially for vulnerable or indigent populations.

My focus on quality and access in healthcare for all populations broadened during my tenure working with large geographies and populations as an experienced healthcare CEO and as a member of numerous boards of directors.

The ability to recruit, develop and retain human talent is essential to the success of any company, and healthcare is no exception. My experience suggests that since 2011, it has become harder to recruit and retain human talent based on each region’s overall access and quality of K-12 education.

In my rural area of Virginia, from a healthcare perspective, recruiting nationally and internationally was challenging for all types of careers, from entry-level professionals, through senior leadership positions. I attributed the recruiting issues to fierce competition over a finite talent pool, but exit interviews and feedback from existing employees and prospective employees indicated that a significant concern was the quality of K-12 education in my area.

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The Wedding Toast: Lessons in Leadership from Love

Recently, I had the opportunity to share the joy and intense emotions of giving away my daughter in marriage. At this extraordinary event, I had the fatherly privilege of making the welcome toast. Reflecting on these thoughts in the days that have passed, I realize that these principles and practices that guide us toward happy and healthier relationships are key traits that great leaders exhibit. Please indulge me in the following excerpt from that toast I gave at the wedding of my daughter Francesca to her husband Matthew.

One of the privileges of being the Dad of a little girl is that she sits on your lap and you have little talks from time to time. One I remember in particular is when her mother was out shopping, because that’s what she did when Daddy and daughter spent time together, Francesca looks me in the eyes and says: “Daddy when I grow up I want to marry you” ….. I had to politely explain to her that Mommy wouldn’t like that too much! She then went on to say: “How will I ever find the right person to marry?” I said: “Honey, when you fall in love and if that person treats you as well as I do, then he’s the one.” Matthew you’ve passed that test.

So I can’t leave without a little advice for Francesca and Matthew…..You are starting your life together, what’s the most important thing? The most important thing is LOVE….that’s a great word but there are a lot of things that go into it. For my colleagues in medicine, you know we have to make acronyms out of everything to help us remember….

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Hats off to the standalone hospital CEO Why I find Rural/Small/Stand-Alone-Hospital CEOs so Impressive.

“Stand alone” hospital presidents provide a great deal to admire.

I was the lead in a recent strategic retreat and the CEO was incredibly impressive as I watched her interact with her board, her physician leadership and her administrative team. Once again it rekindled my awareness of how small hospital CEOs have to do it all. They are the engaged in the community, lead in the facility, influence the physicians, head Human Resources, know all the staff by name and can even be involved in the revenue cycle, IT and compliance departments. There is very little this CEO isn’t aware of from governmental changes to the one physician or nurse who leaves unexpectedly. There is no cushion. There is no room for error. It is a pure survivability issue. They must know everything and be involved in everything. As they look around them, there are few, if any, people to delegate to within the organization. They have the community depending on them as one of the key employers if not the largest of their city. System CEOs on the other hand have delegation capabilities and can look to corporate for support and capital. While a smaller hospital CEO bears the brunt of this responsibility.

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Influencing Your Team: 10 Leadership Traits that Drive the Ability to Influence Teams

All leaders will openly admit that they could not do their job without their team. However, as humans, I’d bet that most of them, in a moment of frustration, have thought “it would be easier if I just did it myself.” Why? Because influencing people is a gradual process, not simply a decision with immediate results.

Accepting the reality that no matter how brilliant or hard-working you are, you will always need your team which means you need to learn how to influence them.

Master the following attributes and you will be well on your way.

10 Leadership Traits that Drive the Ability to Influence Teams

Grateful Attitude - As a leader you are always on stage and therefore need to possess and portray a grateful attitude. Start your day with a ritual that grounds you; whether this is prayer, meditation, exercises, reflecting on loved ones, etc. When your day gets tough, reflect on, or re-enact your gratitude ritual.

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The healthcare leadership matrix, how to create a 'win-win' after the deal is done

The healthcare environment continues to undergo rapid and profound change with mergers, acquisitions and new business models forever changing the landscape of how we lead and deliver healthcare for the next millennium. In my previous article, I discussed the concepts of leading your team through complex problem solving. Today the focus is on you, the leader, how you successfully navigate yourself through new relationships, complex reporting structures and multi-entity healthcare business models.

As leaders in this new matrix and/or multi entity models, we are challenged to rethink our leadership style and model into a much more collaborative and creative approach to be successful. New relationships, business or otherwise require us to lead together, build upon individual and team strengths and become much more resilient to change. In my experience, I’ve had the opportunity to both model and observe what I call best practices when leading in a highly complex and matrix environment:

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Dealing with Narcissism at Work?

Have you experienced any of these characteristics with a coworker or a boss?

  • The need to be “right” all the time
  • Quick to take credit for everything but be the first to assign blame on others
  • Minimize people and their emotions
  • Pit employees against each other
  • Desire to be appreciated and attended to all the time
  • Show no consideration for others or display empathy or compassion
  • Inconsistent behavior – you may be their best colleague/employee one minute and they may be threatening to fire you the next
  • Insistence on compliance with their demands regardless of how unreasonable they might be
  • Complete disregard of ethics, standards and morals, like they are above the law

If any or all these behaviors seem familiar to you, then run as far as you can from this individual, especially if they are your boss! Since that may not always be an option, below are some strategies that will help you deal with narcissists.

  1. Make them look good. Praise and acknowledgement make them tick
  2. Give them the attention they need, within reason. They feel threatened when you do not comply with their own self worth and aggrandization
  3. Do not try to reason or argue with them, it will just aggravate them. Let them talk while you listen
  4. Learn their pet peeves and avoid those. Similarly, learn what is important to them and cater to that
  5. Build a wall – you cannot take anything these individuals say personally. They can be manipulative and abusive, damaging your self-esteem. Disengage with them
  6. Find your drivers – do not expect them to motivate you and do not let them take you down. Keep the fire burning by focusing on what’s important for you
  7. Be proactive. While this is a good management mantra all the time, learn the triggers to narcissistic behaviors and control their occurrence as much as you can
  8. Enhance your emotional intelligence and learn tactics to cope with the behaviors professionally
  9. Let them micromanage or make decisions. They want their way and will get it. If you don’t agree with it voice your concerns but don’t expect to have the final say

Narcissists may be very successful entrepreneurs or professionals owing to their ability to turn on the charm and risk-taking skills, but they make ineffective leaders. Learning how to cope with narcissists in the workplace can be a great lesson in managing up or around!

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How to ‘Stop the Insanity’ and Pave the Way to Real Achievements

I am sure you have heard the old adage “the definition of insanity is to keep doing the same thing over and over again expecting a different result.” I would like to expand to that definition “and doing something without appropriate planning and expecting a better outcome.” Have you ever witnessed an unexpected result or outcome followed by a flurry of activity which is expected to positively impact the outcome? The danger of this reactionary activity is the false sense that the problem is being solved. Reactionary activity may address the fringe of the problem, but the root cause remains festering and aggravating the organization. To help with the risk of confusing activity with root cause problem solving, I suggest the Four Steps to Achievement, or what I like to call P8. Read the Full Article

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The Fourth Discipline: Transition Management

Leadership Transformation Series

This is Part 1 of a Four-Part Leadership Transformation Series (LTS).

2012 Womens Olympic Triathlon finish in London - After two hours of racing with the best in the world, what would one or two seconds in transition time have meant for the top three athletes?

Transformation in healthcare is personal: it requires the transformation of health system leaders. This LTS begins to speak to key differences in some of the fundamentals of transformational vs traditional leadership in healthcare.

This article focuses on how the nature of our work is changing.

Many compare the healthcare transformation journey to one of our oldest Olympic sports: “It’s a marathon!” Although this might reflect the persistence, resilience and endurance sentiment, I offer an analogy upgrade from one of our newest Olympic sports: “It’s a triathlon!”

Why?

First, transformation requires mastery of multiple disciplines. We – and our organizations - may have competency in one or two disciplines, but adaptive learning is required to develop and integrate the different and stronger skills needed for next level or breakthrough performance. We cannot count on simply doing more of the same ‘one foot in front of the other’ plodding and grinding to advance our mission – our people are burning out. Unlike in the run or bike, the first triathlon discipline – the swim - does not ask as much of the legs. While the upper body provides most of the forward propulsion, for swim speed it is more important to reduce drag. Drag is not a material factor in running, but it is in running our organizations – and barnacles, barriers and anchors come in many, mostly self-inflicted, forms.( Read Full Article)

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Want to build your culture -- start by sweeping the floor!

Over the years, I’ve heard many stories, inspirational stories on leadership, one of my favorites involves President John F. Kennedy and his first visit to NASA in 1962. As the story goes, the President was touring the facility when he came across a janitor carrying a broom down the same hallway as the touring President. Kennedy, a great lover of people stopped him and asked him what he did for NASA, not missing a beat he replied, “I’m helping to put a man on the moon”.

As I reflect on this, I’m struck by the absolute simplicity of this statement, but also the way it speaks volumes. This individual clearly understood that he was an integral part of the team, no matter what the role. If he did his job well, he contributed to the overall success of the team, engineer, scientist, astronauts etc. His job, although different in almost every way imaginable from his colleagues, still contributed to achieving the overall goal, that of putting a man on the moon. Read Full Article

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Focus on Culture for Patient and Family Care: Beyond the Medicine

As healthcare (including acute care, nursing homes, home health and all downstream providers) moves towards a greater focus on patient/family satisfaction, the model of healthcare must also evolve, for both the government and patients/families will be closely reviewing these in determining healthcare provider(s) of choice. A satisfied patient is a more compliant patient, making for a more engaged patient. Providers at every level must now move beyond the patient centered approach, into an understanding of the patient/family perspective and be willing and able to convert input to action and measurable goals, benefiting staff, patients and families. Read Full Article

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Healthcare Integration: Ship-to-Shore Work and the Ultimate Weapon

Veterans Day reminds me of my father. In WWII, he landed on Omaha Beach on D-Day.

As Steven Ambrose details in his book “D-Day,” the Allies planned the Normandy invasion for three years, but as soon as our troops hit the beaches, the plans went out the window. To the ‘man on the ground,’ NOTHING was as planned. And on the beaches, formal leaders were dead or not available. Survival and progress to save the free world depended on rapid learning and action, i.e., adaptive leadership. Our troops felt empowered to act, German forces felt compelled to wait for Hitler’s direction. The rest of this leadership story, as they say, is history.

Despite asserting to my Dad, in my youth, the growing impact of technology, e.g., pilotless planes, long-range capabilities, etc., he remained convicted of the mantra “the ultimate weapon is the man on the ground.”* My Dad and his colleagues, some of whom made it past D-Day, are heroes. I have since learned that there were others “on the ground” back in the U.S. who heroically enabled these heroes. During the planning for the largest invasion in modern history, a significant challenge was figuring out how to get our troops from ‘ship-to-shore.’ The U.S. federal government knew how make large ships to get our troops across the English Channel, but they could not get our troops to the shore. Enter Andrew Jackson Higgins, who was described by Dwight D. Eisenhower in 1964 as “the man who won the war for us.” (Read Full Article)

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Is it 'Mission Impossible' for healthcare? Why mission-driven leadership is still the answer.

Healthcare has been in a tremendous period of change, mergers, acquisitions, leadership restructures, and new and improved strategic plans and priorities fill the time of most leaders. During this time of change, many leaders may wonder privately, does the mission of this organization still matter? Or is it only about the bottom line?.

When looking at high performing companies outside of healthcare, they all share some things in common, first, they have a clear and well spelled out purpose/mission. This is important so everyone, front line staff to executives can understand the why we are here, and how we will define success. This is not just a feel-good statement, and properly developed and executed this has the potential to pull people forward, especially during uncertain or difficult times. Read Full Article

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Does your new hire have the right stuff? How their personality has a long-term impact on your organization’s bottom line.

In healthcare, how often have you heard this, he/she is a great clinician, but has no personality. Or, take me to hospital A, but if I’m really sick take me to hospital B, this assumes hospital A is the “Nice” hospital but Hospital B is where all the best clinicians work. So, the obvious question is, can’t you have both? Yes, if you select the right people.

In Jim Collins book, “From Good to Great”, he writes, “People are your most important asset,” or rather the right people are. In today’s healthcare market many organizations are making the move from Volume to Value, with Quality being a primary focus, but how do our patients define quality? Sure, having the best possible outcome is right up there, with no medical mistakes or errors please. However, most patients come to our organizations assuming great quality, and value the interaction with their caregivers as high if not higher than any other part of the patient/caregiver interaction. Read Full Article

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Are you holding your team back? Why task-oriented leaders should build their relationship skills to accomplish goals

Task oriented leaders, those using just workplans, measurements, goals, dashboards, etc.… sometimes may be left scratching their heads when their teams do not accomplish their goals, or performance begins to decline without any clear reason as to why.

To motivate your teams, and accomplish your goals, perhaps you would be better served to examine your leadership relationship competencies.

WHAT IS RELATIONSHIP LEADING?

WHAT IS TASK-ORIENTED LEADING?

When determining what leadership style works best for your team, consider the make-up of the team, today’s workforce is motivated much more by team achievement but still values individual recognition. Workers today want to achieve the goal, but want much more flexibility than past generations when it comes to how to achieve that goal. Read Full Article

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New Year’s Resolution: Become A Better Leader!

In all the hustle and bustle of the holiday season, it’s easy to forget that in just a few weeks most of us will be looking at the New Year and a list of resolutions or promises that we have made to ourselves that we hope to accomplish. Some of our old favorites are bound to make the list, lose some weight, exercise, give more to charity, get back in touch with family or old friends.

But what about including in this year’s list the commitment to be a better leader next year?

Research tells us that when we write our goals down, we are far more likely to achieve them, so begin the year by taking a good hard look at what is means to be a leader, remember, you may have the title but being the leader of people requires these fundamental building blocks, can you complete these? Read Full Article

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Congrats you got the job! Read before you sign.

A physician who I greatly admire and respect once took a job as a hospitalist in a small town. She was told that she would have a guaranteed salary. But she did not read the fine print in her employment contract. The guarantee was actually an advance against future production, or collections. She was required to meet a certain level of collections to support her salary. If she did not meet that level of collections, she had to pay back the deficit. There was a hospitalist outside of and competing with her group. One of the emergency department physicians really liked this hospitalist. If he determined that the patient had good insurance, he called the outside hospitalist to do the admission. If he determined that the patient did not have good insurance, he called my friend’s hospitalist group. They were providing a tremendous amount of care to the patients in the hospital. They were just not getting paid. The longer she worked there, the deeper in debt she was getting. One of her partners did the math and simply left. My friend stayed out of a sense of integrity and fairness to give them time to find her replacement. She was not repaid in kind. And who was going to come and take over for such a terrible deal? She ended up in court and had to pay everything that the hospital was demanding of her. The judge said that it was a terrible contract, but a legally binding one and that she was a big girl and should have read the contract. Her partner who left early made the right decision in that she paid much less to the hospital.

When I was in medical school, we had a medical legal course which consisted of about 10 hours of lectures. One of the things that we were told was to read very carefully anything that we put our signature to. We were particularly cautioned to read employment contracts. I have followed this advice, and it has served me very well. I know of some stories where physicians were badly injured for not having read their employment contracts.

The first question is, “Will I be paid as an employee or as a contractor?” If an employee, then the employer pays half of the Social Security and Medicare taxes. If a contractor, then you pay all of the Social Security and Medicare taxes. If paid a salary, you will get a set amount of money, usually every two weeks or every month. Most people who are paid a salary are expected to work significantly more than 40 hours per week, because there is no additional cost to the employer for extra hours that you work. Many job offers will sound like salaried positions, but close examination of the contract will reveal that all or a significant portion of the payment offered is contingent upon one or more performance metrics. These metrics may include collections, relative value units (RVU’s), quality & efficiency. These may be based on individual performance, group performance or some combination of both. Collections is how much was actually paid for the care you delivered. Usually, a percentage of your collections is paid to the group or hospital for overhead. RVU payment is based not on collections, but on billing. This system is often used by organizations that serve the underserved as it encourages physicians to deliver care regardless of an individual’s ability to pay. Increasingly large portions of physicians’ compensation packages are only paid if the individual and/or group meet certain quality and efficiency metrics. Whether you are actually in control of a metric, the manner in which the metric is tracked & calculated and the thresholds to qualify for the metric all can have significant impact on your actual compensation. Benefit packages can also have significant impact.

In such a short article, I cannot tell you everything to look for. I would advise you to look closely at the exit clauses. When you go to work for a new employer, you have great hopes and even expectations that things are going to go very well. But they may not. I heard of a physician who, within two months of joining a new group, learned that his partners were engaged in and engaging him in activity of questionable legality. The exit clauses in his contract were onerous, and it was very costly for him to leave so early. Issues that may hit you with early separation can include repayment of sign-on bonuses, repayment of moving stipends and noncompete clauses. I was once invited to sign a contract that said I could not work for two years in any hospital anywhere in the United States owned by any company or organization that had a contract with this large physician staffing company (which had hospital contracts in many states).

So how do you go about reading an employment contract? Of course, you are not going to receive a copy of the contract until after you have been given an offer of employment. The contract is usually sent as a PDF. You can either print it out and use a highlighter and an ink pen or, if you can get it into an editable format on your computer, you can go through the document using track changes. You are now going to sit down and read every single word of the document: slowly, carefully and thoughtfully. You will go online and look up the definitions of any legal terms that you do not understand. You can write those definitions in the margins. You can make notes about things that you understand and want addressed and about things that you do not understand. After fully digesting the document, you will either decide to walk away from this job or you will think that this might be doable if the potential employer is agreeable to reasonable changes.

If you wish to go forward, you will now hire an experienced physician employment attorney and will send him or her a copy of your highlighted document with all its notations. You will discuss your concerns. Your attorney will review your document and schedule a follow-up discussion. Your attorney may advise you simply to walk away. Or he may give you a list of items that need clarification or correction. Some issues you identify and some of your attorney’s recommendations will be deal breakers meaning either these changes are made, or you refuse the offer of employment. Others may be that it would be nice if you could get them, but are not that important. With the help of your attorney and your spouse or significant other, if there is one, you will formulate a plan for seeking necessary and desired changes in your employment contract that are reasonable and fair to both parties. Your attorney will help you express your concerns in a language that resonates with the attorney working for your potential employer who will have to give the final approval on any changes to the employment contract.

I will walk you through how I approach these negotiations. I schedule a phone meeting with the individual designated by the potential employer to be their face for the negotiations. My tone is very pleasant and reasonable. I start by saying that my wife and I have carefully read the contract. I have sought the advice of a very competent attorney experienced in physician employment contracts. From these discussions, the following concerns have arisen. If the concern is coming from me, I do not hesitate to say so, but I consider it a good strategy to point out when the concern is coming from my wife or from the advice of my attorney. This is called an appeal to higher authority. It may seem like weakness, but it is a very powerful tool. Used properly, it can tremendously strengthen your position as nothing they say to persuade me will have any impact on how my wife feels about it, especially when it is an issue that is recognized as a reasonable concern for the employee’s wife. When appropriate, I ask for clarification of language in the contract rather than outright changes. Everything that I am asking for needs to be laid out in this first meeting. If you keep coming back with new demands, they may tire very quickly and look for another candidate.

You likely will not get everything you ask for. Just make sure that you get everything you need.

You likely will not get everything you ask for. Just make sure that you get everything you need.

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