Overcoming Hurdles for Soon-To-Be Practitioners, The Rising Chief Resident Summit - Tom Stringer
September 26, 2019
Tom Stringer joins Neal Shore to share highlights of his presentation at the first Rising Chief Residents Summit put together by the Large Urology Group Practice Association. This summit aims to support post-graduate year 4 and 5 residents during their transition to full-time practice. Dr. Stringer presented on crucial topics including vetting employment contracts, pursuing a career in academia, hospital-employed, industry employed, community, and independent practices. He also covered physician and practice agreements and what you don't know could hurt you, as well as resident training interests, future residency training, what's changed in part with resident training, the duty hour requirement, and business training. The final year of residency is filled with hurdles for soon-to-be practitioners. It is essential for urology residents to consider all potential career paths including positions with independent urology practices. The Rising Chief Resident Summit offers residents an opportunity to personally engage with key leaders from some of the largest independent urology practices in the country.
Biographies:
Thomas F. Stringer, MD, FACS Associate Chair Clinical Associate Professor Department of Urology, UF Health, College of Medicine
Neal Shore, MD, is the Medical Director of the Carolina Urologic Research Center. He practices with Atlantic Urology Clinics in Myrtle Beach, South Carolina. He serves on several industry advisory boards as well as academic and advocacy networks: including the Society Urologic Oncology Clinical Trials Consortium, Bladder Cancer Advocacy Network, and the Large Urology Group Practice Association.
Biographies:
Thomas F. Stringer, MD, FACS Associate Chair Clinical Associate Professor Department of Urology, UF Health, College of Medicine
Neal Shore, MD, is the Medical Director of the Carolina Urologic Research Center. He practices with Atlantic Urology Clinics in Myrtle Beach, South Carolina. He serves on several industry advisory boards as well as academic and advocacy networks: including the Society Urologic Oncology Clinical Trials Consortium, Bladder Cancer Advocacy Network, and the Large Urology Group Practice Association.
Read the Full Video Transcript
Neal Shore: Hi, I'm Neal Shore. I'm here today at the Rising Chief Resident Summit, San Diego, 2019. It's our first Rising Chief Residents Summit put together by the Large Urology Group Practice Association. And it's really a great privilege for me to have a conversation here with my friend and colleague for many years, Tom Stringer. Tom, you gave a presentation today on a physician agreement, practice agreements and what you don't know could hurt you.
Tom Stringer: Right.
Neal Shore: A fabulous presentation. I want to hear some of the keys to that presentation, but I think coming from you, the arc of your career has been truly representative of so many aspects of urology. You've had a big community practice before large urology groups were even starting. You had one of the first early big groups. You've had an incredibly successful career in academia, and you've been very involved in association leadership at the level of the American Urological Association, the Florida Urological Society. And now you're still in academia, but you really understand so many facets. So talking today to residents compared to how we approached employment contracts, it's just changed enormously.
Tom Stringer: Right.
Neal Shore: So how did you get interested in this area? And then I really want to hear some of the key pearls.
Tom Stringer: Well you're right, I've had a career that spans several [inaudible 00:01:32], sorry. It started with a private practice, ended up expanding and growing to private practice and looking into ancillary income streams, developing new business models and growing a practice in a rural community setting. But I always stayed connected to the university where I train. The University of Florida was just an hour and a half away. So I served as an adjunct professor for almost 30 years. I was one of only two community physicians on the Task Force for the AUA in 2006, looking at the future residency training. Several things came out of that. The core curriculum came out of that. An accelerated pathway through internship came out of that.
So I always had some of that academic interest, resident training interest, and moving up the street a little bit for a career in academic medicine and teaching was important to me too. Certainly this exposure, we've all seen that the changes in private practice, which has encompassed less and less interest in entrepreneurship, developing a practice, dealing with the administrative workload that's required to have a successful practice, and then more and more physicians than seek employment.
But it's not just the regionally finishing residency, it's physicians in practice that are now seeking an alternative to their own private practice. So it seemed to me that there was a real need to discuss employment contracts. What's changed in part with resident training is the duty hour requirement. For those that don't know, residents are required not to work over 80 hours a week. There's really less and less opportunity for this sort of training. Enough of their time is required for clinical training and much less time available for business training. Although the core career includes business and communication, and we see this including the last census, that residents, in particular, don't feel comfortable in addressing business issues after their clinical training. 97% feel comfortable or ill-trained to deal with compensation agreements or employment contract.
Neal Shore: That's a phenomenal number, but I have to say, when I finished in 1990, my first contract, I remember it vividly. It was a page and a half, it was mostly a handshake. I didn't bring it to an attorney. I just said, seems like a good deal, and now I look back on it. Wow. There's a lot of things I had no clue about other than I just wanted to practice urology.
Tom Stringer: Right.
Neal Shore: So, you alluded to the fact that it's not even just residents and fellows looking for jobs, but that's what we're here at the summit to try to help. The presentations today were pretty balanced on a career in academia, a hospital employed, industry employed, and in community, in independent practice. But today it's a very different world. There are work life balance issues, there are constraints on residency time in terms of actual training. So what are some of the things that you would tell viewers today, residents, fellows, and even somebody who might've started in a job a couple of years later, they're looking for a new job, and they're trying to really say, what do I look at in this contract? Of course, you could always give it to an attorney and maybe that's a good thing. How do we get better educated?
Tom Stringer: Well, part of what we discussed today, of course, went through the aspects of an employment contract. You do point out something interesting that you don't always stay at your first job. We have some information across medical specialties that about within three years, half of the physicians have left their first job. We don't know exactly how that applies to urology, but your first job is not always your last job. So you have multiple opportunities to look at the aspects of an employment contract. So we talked about today, we talked about compensation, we talked about benefits, we talked about covenants of a contract, we talked about restrictive covenants as well as far as staying in the same practice area or geographic area that you start, and if you leave the job, what that may mean. We've talked about other business transactions. We talked about buying into a practice.
We talked if you're going to buy in your practice, you're gonna at some point want to sell that ownership interest. We've talked about selling your medical practice, which brings into consideration state and federal laws. It's fraud and abuse and a kickback, stark, et cetera. So it is more complex, and I'd have to agree that I probably spend even less time than you did with my first contract. We've given this course at the AUA for a number of years, seven, eight years. In the course, my course instructors, including a contract attorney, and include a hospital administrator.
Neal Shore: Yeah, and there's a lot of detail to all this, and it's really great. We're going to be able to get ... folks who are watching this will be open to download your slide presentations, which is extremely generous of you. If you had to put ... I hate to put you on the spot, but it may be there was maybe two, three things that are particularly anxiety-provoking for residents and fellows as they try to think about this agreement, whether it's with a hospital or an independent group. Of course, as anybody going out there and starting solo practice and hanging a shingle, which I think is a final jeopardy question, what is it to hang a shingle. No one does that anymore.
Tom Stringer: 10%, according to our most recent survey, 10% of urologists, 9.8% are in solo practice.
Neal Shore: Coming out of residency and fellowship?
Tom Stringer: No, overall.
Neal Shore: Overall, yeah.
Tom Stringer: Yeah. So, you're right. I think that the people leaving residency have anxiety, certainly, that would predict they're not going to want to start their own practice. But I think the anxiety, as far as that contract, I think what I find when I talked to my own residents is that they struggle to negotiate on their own behalf. They don't feel that they're entitled to ask questions that they may inherently have, and they feel like if they do, that they may come across as too assertive, too demanding, and jeopardize their hire. And I encourage them that they have every right to ask these questions. I helped them with some of their questions, but in the final event, I think they feel intimidated to be in this position they've never been in before. It's their first job.
Neal Shore: Yeah. So that's great, that's really a great insight, coming from someone like yourself with all this experience. I think within the content of your slide presentations, there'll be a lot of other insights. So, I think with that, Tom, thank you so much for being here. Thanks for everything that you've done at AUA. Thanks for participating at this LUGPA Rising Chief Resident Summit. We owe you a great deal and really appreciate it.
Tom Stringer: I appreciate our years of friendship as well. Thank you.
Neal Shore: Thank you.
Tom Stringer: All right.
Neal Shore: Hi, I'm Neal Shore. I'm here today at the Rising Chief Resident Summit, San Diego, 2019. It's our first Rising Chief Residents Summit put together by the Large Urology Group Practice Association. And it's really a great privilege for me to have a conversation here with my friend and colleague for many years, Tom Stringer. Tom, you gave a presentation today on a physician agreement, practice agreements and what you don't know could hurt you.
Tom Stringer: Right.
Neal Shore: A fabulous presentation. I want to hear some of the keys to that presentation, but I think coming from you, the arc of your career has been truly representative of so many aspects of urology. You've had a big community practice before large urology groups were even starting. You had one of the first early big groups. You've had an incredibly successful career in academia, and you've been very involved in association leadership at the level of the American Urological Association, the Florida Urological Society. And now you're still in academia, but you really understand so many facets. So talking today to residents compared to how we approached employment contracts, it's just changed enormously.
Tom Stringer: Right.
Neal Shore: So how did you get interested in this area? And then I really want to hear some of the key pearls.
Tom Stringer: Well you're right, I've had a career that spans several [inaudible 00:01:32], sorry. It started with a private practice, ended up expanding and growing to private practice and looking into ancillary income streams, developing new business models and growing a practice in a rural community setting. But I always stayed connected to the university where I train. The University of Florida was just an hour and a half away. So I served as an adjunct professor for almost 30 years. I was one of only two community physicians on the Task Force for the AUA in 2006, looking at the future residency training. Several things came out of that. The core curriculum came out of that. An accelerated pathway through internship came out of that.
So I always had some of that academic interest, resident training interest, and moving up the street a little bit for a career in academic medicine and teaching was important to me too. Certainly this exposure, we've all seen that the changes in private practice, which has encompassed less and less interest in entrepreneurship, developing a practice, dealing with the administrative workload that's required to have a successful practice, and then more and more physicians than seek employment.
But it's not just the regionally finishing residency, it's physicians in practice that are now seeking an alternative to their own private practice. So it seemed to me that there was a real need to discuss employment contracts. What's changed in part with resident training is the duty hour requirement. For those that don't know, residents are required not to work over 80 hours a week. There's really less and less opportunity for this sort of training. Enough of their time is required for clinical training and much less time available for business training. Although the core career includes business and communication, and we see this including the last census, that residents, in particular, don't feel comfortable in addressing business issues after their clinical training. 97% feel comfortable or ill-trained to deal with compensation agreements or employment contract.
Neal Shore: That's a phenomenal number, but I have to say, when I finished in 1990, my first contract, I remember it vividly. It was a page and a half, it was mostly a handshake. I didn't bring it to an attorney. I just said, seems like a good deal, and now I look back on it. Wow. There's a lot of things I had no clue about other than I just wanted to practice urology.
Tom Stringer: Right.
Neal Shore: So, you alluded to the fact that it's not even just residents and fellows looking for jobs, but that's what we're here at the summit to try to help. The presentations today were pretty balanced on a career in academia, a hospital employed, industry employed, and in community, in independent practice. But today it's a very different world. There are work life balance issues, there are constraints on residency time in terms of actual training. So what are some of the things that you would tell viewers today, residents, fellows, and even somebody who might've started in a job a couple of years later, they're looking for a new job, and they're trying to really say, what do I look at in this contract? Of course, you could always give it to an attorney and maybe that's a good thing. How do we get better educated?
Tom Stringer: Well, part of what we discussed today, of course, went through the aspects of an employment contract. You do point out something interesting that you don't always stay at your first job. We have some information across medical specialties that about within three years, half of the physicians have left their first job. We don't know exactly how that applies to urology, but your first job is not always your last job. So you have multiple opportunities to look at the aspects of an employment contract. So we talked about today, we talked about compensation, we talked about benefits, we talked about covenants of a contract, we talked about restrictive covenants as well as far as staying in the same practice area or geographic area that you start, and if you leave the job, what that may mean. We've talked about other business transactions. We talked about buying into a practice.
We talked if you're going to buy in your practice, you're gonna at some point want to sell that ownership interest. We've talked about selling your medical practice, which brings into consideration state and federal laws. It's fraud and abuse and a kickback, stark, et cetera. So it is more complex, and I'd have to agree that I probably spend even less time than you did with my first contract. We've given this course at the AUA for a number of years, seven, eight years. In the course, my course instructors, including a contract attorney, and include a hospital administrator.
Neal Shore: Yeah, and there's a lot of detail to all this, and it's really great. We're going to be able to get ... folks who are watching this will be open to download your slide presentations, which is extremely generous of you. If you had to put ... I hate to put you on the spot, but it may be there was maybe two, three things that are particularly anxiety-provoking for residents and fellows as they try to think about this agreement, whether it's with a hospital or an independent group. Of course, as anybody going out there and starting solo practice and hanging a shingle, which I think is a final jeopardy question, what is it to hang a shingle. No one does that anymore.
Tom Stringer: 10%, according to our most recent survey, 10% of urologists, 9.8% are in solo practice.
Neal Shore: Coming out of residency and fellowship?
Tom Stringer: No, overall.
Neal Shore: Overall, yeah.
Tom Stringer: Yeah. So, you're right. I think that the people leaving residency have anxiety, certainly, that would predict they're not going to want to start their own practice. But I think the anxiety, as far as that contract, I think what I find when I talked to my own residents is that they struggle to negotiate on their own behalf. They don't feel that they're entitled to ask questions that they may inherently have, and they feel like if they do, that they may come across as too assertive, too demanding, and jeopardize their hire. And I encourage them that they have every right to ask these questions. I helped them with some of their questions, but in the final event, I think they feel intimidated to be in this position they've never been in before. It's their first job.
Neal Shore: Yeah. So that's great, that's really a great insight, coming from someone like yourself with all this experience. I think within the content of your slide presentations, there'll be a lot of other insights. So, I think with that, Tom, thank you so much for being here. Thanks for everything that you've done at AUA. Thanks for participating at this LUGPA Rising Chief Resident Summit. We owe you a great deal and really appreciate it.
Tom Stringer: I appreciate our years of friendship as well. Thank you.
Neal Shore: Thank you.
Tom Stringer: All right.