What physicians wish they’d known in residency

As a resident or fellow on the job hunt, you may feel a lot of pressure. Financial pressure. Peer pressure. Perhaps above all, the pressure to impress potential employers. After all, you’ve been a high achiever throughout your training, and you want to succeed here, too.

The good news: Physicians who’ve gone before you are happy to help—whether they’re a few years out of training, nearing retirement or somewhere in between. They’ve learned a thing or two since leaving residency, and they’re glad to share what they wish they’d known in your shoes. Here’s advice from  physicians and seven of the lessons they learned along the way. Here’s what physicians wish they’d known in residency:

1. It’s time to put yourself first—for the greater good

Kristin Miller, M.D., a family medicine physician with a hospital system in Oklahoma, says, “I didn’t learn to advocate for myself in residency. I was always a people-pleaser. I thought that was how you win in life. But I’ve learned it’s actually the opposite. When you advocate for yourself and know what you need and you’re advocating for being the best version of yourself, that’s how you win.”

Now that hiring physicians is part of her job, Miller understands even more how important it is to be forthright during the interview process. “In residency, your goal is to get every single person to like you and want you. But in job hunting, you need to be choosy—and not just for yourself. It’s only a win-win if you like them and they like you. This is a dynamic residents aren’t used to.”

Miller says residents may shy away from asking important questions during interviews because they don’t want to seem impolite. But if you don’t get the answers you need, you’re likely to wind up in jobs that don’t suit you. And when unhappy physicians leave soon after they’re hired, it’s not just a loss for them. It also costs their employers. Recruiting is expensive. Plus, physicians who exit within a year or two rarely reach a profitable level of productivity.

That’s why savvy employers look for signs that candidates have done their homework, Miller explains. Smart, detailed candidate questions will show employers that you’re interested and engaged. In fact, if you don’t ask meaningful questions, you may limit your opportunities.

“We don’t want to hire people who don’t ask questions,” she says. Her hospital looks for evidence that candidates understand the work environment and want to become part of the culture. “We want people who are all in,” she adds.

2. The right job might not be advertised

Oluwatoni Aluko, M.D., MPH, a family medicine physician in Philadelphia, didn’t hear much about networking during residency. Instead, she found out just how powerful networking is through direct experience. She wasn’t shy about exploring her interests—and it helped boost her career.

“You will get a lot of emails from recruiters,” Aluko acknowledges. But just because a job isn’t posted doesn’t mean it’s not available. “Connecting with physicians firsthand gives you insight into what positions are available, many of which may not be advertised.”

During rotations in her residency at the University of Pennsylvania, Aluko started learning about the clinical scope of student health clinicians. She found herself drawn to that field and took the initiative to find out more.

“I reached out to an adviser to see if it was possible to create an elective in student health,” she says. That contact led to a personalized elective and, not long after that, a job offer at Penn. “When I was ready to work and a position became available, the medical director and my colleagues in student health remembered me. [The elective rotation] was instrumental to me being top of mind when a position came open.”

Now Aluko wants residents to know that investigating out-of-the-box interests can lead to opportunities that aren’t part of the annual recruiting process. These opportunities might be a much stronger match for your interests.

And even if asking questions or reaching out doesn’t result in an immediate job offer, Aluko stresses that this effort isn’t wasted. Making relevant connections can put you in line for job openings down the road. “The worst they can say is there’s nothing open,” Aluko says. “But at least you can ask. In the world of medicine, people talk. They remember you and refer you on.”

Adrienne Youdim, M.D., a physician, author and entrepreneur in Beverly Hills, California, also took an atypical path early in her career. She had always been interested in the technical side of medicine and pursued a fellowship in gastroenterology. “I matched in a very competitive fellowship, [but] when I got pregnant, I decided I had to drop it,” she recalls. “But then I thought: ‘What can I do now?’”

Changing her plans was difficult, as was leaving behind a hard-won spot. Her way forward was unclear. But that uncertainty helped Youdim think more expansively about her options. When she learned about the surgical weight loss practice at Cedars-Sinai in Los Angeles, she approached the center about creating a medical counterpart.

“I started up the center for medical weight loss at Cedars and ran it for 10 years. We transitioned [the program at Cedars] from surgical weight loss only to both medical and surgical. We created a comprehensive program, and I became its co-director.”

The experience gave her the confidence—and the platform—to pursue other interests, such as entrepreneurship and publishing. Since her time at Cedars, she’s started her own practice and launched a nutrition line. She also recently published a book: “Hungry for More.”

“I learned from patients that their desire for food is really a hunger for something else, and I thought about how that [process of introspection] applies to me as well,” she says. “For me, the lack of autonomy in employed practice was not conducive to my goals. I had a lot of creative pursuits I was interested in.”

Given how long it takes to become a physician, contemplating a less predictable path is no small matter. But Youdim will tell you it’s been more than worth it. “There’s so much benefit to giving yourself permission to evolve, to go where you need to,” she says. “It doesn’t mean you’re not working hard. I am probably working harder now [than when I was employed]. But I have autonomy. I have purpose. I have creativity.”

3. Conventional wisdom isn’t always so wise

Looking back, some physicians say the conventional wisdom you hear in residency can be wrong—or at least wrong for you. There’s no harm in questioning if what everyone says is true. Doing so might open the door to a better fit.

“During training, you hear strong biases against certain practice types. Don’t let others’ views influence you. Independently evaluate each type—and each individual practice—for yourself,” says Jay Wofford, M.D., a dermatologist and dermatopathologist with U.S. Dermatology Partners in Dallas, where he is also the group’s North Texas regional president.

For example, many doctors have negative views about private equity financing. But the more Wofford learned about private equity-backed U.S. Dermatology Partners, the more he believed their way of doing things matched up with his goals.

He’d be able to divide his time equally between a general dermatology practice and pathology work. It helped that the group’s lead marketer had invested significant time building relationships with physicians in Wofford’s residency. Wofford met with her, got answers to all his questions and left with a clearer picture of what the group had to offer.

In some residency programs, there’s also negative buzz about private practice. Critics point out that being employed by a larger organization lets you spend more time as a doctor without all the management details of running a practice.

But if you’re curious about private practice because of the added autonomy and business benefits, you owe it to yourself to explore more. After all, many specialties are in high demand. Even if you try out a private setting and discover you don’t like it, you’ll likely be able to find employment in a health system or hospital easily.

If you want to understand what any type of organization or practice is really like, Wofford says there’s no better resource than physicians who currently work there. He urges residents to stay in touch with colleagues. “Keep in touch with residents a year or two ahead of you who have similar interests,” he suggests.

“Find out how they started their search and narrowed it and get feedback from them as they start in the jobs. You can learn from their successes and mistakes.” About six months after these colleagues start work is a good time to reach out. Wofford adds, “Ask them if there’s anything they wished they’d asked during interviews.”

4. Learn about the business side—and understand your compensation

Elizabeth Chiang, M.D., PhD, an ophthalmologist and oculoplastic specialist in Cleveland, found herself drawn to private practice. She was excited about hiring her own staff and establishing a more flexible schedule. As she completed her training, she looked for a private group where she’d be able to join on a partnership track and found multiple opportunities to consider. To choose one, she needed to ask the right questions.

Once Chiang homed in on a practice to join, she asked the owner for financial documents. Then she enlisted her mother (a CPA) and her sister (a businesswoman) to confirm the business was financially sound. Chiang liked a lot about that first job. Eventually, however, she learned some important but frustrating lessons. “It was a good practice and well run,” she says. “Support staff was great, and I had the flexibility I wanted. The problem was: I wasn’t busy enough.”

The practice owner had a limited marketing budget for Chiang’s new practice and wasn’t willing to increase it. Chiang was prepared to work hard to earn more, but without more marketing support, she couldn’t grow her patient base—or her compensation—as much as she wanted to.

Now Chiang advises job-hunters to ask why the job they’re applying for is open. Is a physician retiring? Or is the practice growing and adding staff? “If they say they’re hiring because of growth, ask how fast the practice is growing and how they will support you with marketing,” she says.

Wofford agrees. Productivity and income are influenced by many factors outside a physician’s control. He urges residents to learn about these factors and ask about them in interviews. For example, he says, your productivity may hit a ceiling if you lack staff support. Candidates should ask employers what determines when physicians can add a nurse or medical assistant.

“I wish I’d paid more attention to the practice management side of medicine,” he says. “In residency, it’s so easy to focus only on learning your specialty. That’s obviously of the utmost importance. But once you get that underway, take a look at practice management. You need to understand it to make an educated choice.”

You also need to understand exactly how your compensation is calculated. When pay is based on a percentage of collections, some residents get too focused on the percentage itself. “They’re hung up on 35 percent or 40 percent or 45 percent,” Wofford explains. But those numbers don’t mean anything by themselves.

He adds, “The same percentage may be very different dollar amounts in two practices, even if they’re next door to each other.” To get a truer sense of your earning potential, Wofford suggests asking potential employers about their payer contracts and reimbursements.

“I wish I’d paid attention to billing and coding as a resident,” Chiang says. “I only started learning as a fellow how to code for surgery. Coding as a new attending was overwhelming. By then, it was so much to learn.”

Chiang points out that residents and newly employed physicians often underestimate the importance of doing billing-related tasks accurately. She advises residents: “Talk to your attending to learn what is required to support billing at each level. This is what gets you those RVUs or collections. If [your documentation is] not right and you’re audited, you might even have to pay back money.”

5. Know your worth—and protect it

Knowing how much you can—and should—expect to be paid is one of the most difficult and mysterious parts of the job search. This information often isn’t readily available, and it can feel awkward to ask about.

Aluko suggests researching compensation data for related jobs online to see if an offer is in the right ballpark. But she’s quick to add that it’s OK to reach out and ask for help. If she’s interested in a particular organization, she’s not shy about contacting people she knows who work there.

“I called someone once and just asked straight up, ‘What’s the pay?’ People aren’t always willing or allowed to disclose. But I try to ask as much as possible,” says Aluko.

“For many [physician] jobs, people can have a lot of negotiating power, especially in a field like family medicine. I’ve learned anecdotally from talking to [other] female providers, we don’t always negotiate for ourselves. But you definitely have to know your worth. Each job makes a big difference in your trajectory and your salary later on down the line.”

Miller agrees. “Especially when it comes to money, we get uncomfortable about advocating for ourselves,” she says. “We’ve learned that religion, politics and money are impolite to talk about. So maybe you don’t want to lead out with it. But as interviews progress, you will get comfortable, and then you’ll have an opportunity to ask.”

She caveats that if you’re in a group interview, you may not want to discuss these specifics in front of everyone. “You can wait until you’re one-on-one with the recruiter, then you can be frank,” she explains.

6. Nurture your financial freedom

After years and years of hard work with little income—and usually mountains of debt—physicians often want to upgrade their lifestyles when they finish residency. For many, that means buying a nice house soon after they land their first job. The problem? This adds another big responsibility to your list, and if you don’t end up loving that first job, a mortgage can make you feel trapped.

“Chances are your first job is not going to be where you’ll stay long-term. Don’t buy your dream house right away,” Chiang says. “…Make sure you are really at the point you can be certain before buying.”

If you can avoid financial traps like paying down debt too slowly or living beyond your means, you’ll have more flexibility to modify your career in the future. Reducing lifestyle inflation will give you the freedom to work less—and earn less—if you choose to.

When she started her career, Miller was able to earn a lot of money right away, but it wasn’t as satisfying as she’d hoped. She explains, “Four years ago, I was super successful. I was in the top 1% of female earners. It all looked great from outside, but I wasn’t happy. I thought, is this it? What is wrong with me?” A life coach helped her gain clarity about what she really wanted. She then reset her priorities and made positive changes to her work life.

7. Don’t postpone happiness

Miller’s experience may reflect a promising new trend among physicians. When she told colleagues about her experience with life coaching, so many asked her to coach them that she trained to become a coach for physicians herself. Chiang did the same. “I want to focus on helping doctors not feel like they’re on the hamster wheel,” she says.

In residency, Chiang began observing a self-defeating phenomenon: physicians putting off career and life satisfaction. “You go through residency thinking, ‘It’ll be better when I’m a fellow.’ Then in fellowship, you think, ‘It’ll be better when I graduate,’” she explains. “What I’ve learned is that it doesn’t have to be about waiting until the next stage. It’s about what you create. The mindset piece I learned in coaching taught me it’s not just about getting things done. It’s about how you feel in the process.”

Ironically, the COVID-19 pandemic opened the door to Chiang’s new outlook by forcing her to take time off.

“Because we shut down for a while, I only worked one to two days per week,” she says. “Things were happening online that hadn’t been online before. I went to a free conference about physicians leveraging their experience and doing more than just being a physician. I heard about physicians doing real estate and venture capital, being expert witnesses, physicians who are life coaches. It was eye-opening. I was in a place where I could interact with doctors doing all these amazing things besides just being a doctor.”

In one course, Chiang explored real estate investing as a path to financial independence and early retirement. She now owns two investment properties and divides her time between medicine and business pursuits. This change has helped her continue enjoying her medical career while avoiding burnout.

Establishing boundaries and finding balance are key to a satisfying, sustainable career, according to Aluko. “In a field like family medicine, patients are constantly in contact,” she says. “Sometimes we get calls from patients we haven’t even seen before.” And it’s not just that patients are just calling. They’re also messaging physicians via patient portals and expecting quick responses.

To manage the load, many physicians wind up putting off important tasks like charting. Often, they take work home with them, risking overwork and burnout. “Do today’s work today. Rather than letting things pile up, be strategic about getting things done,” Aluko advises. “I ask myself, ‘What can I delegate?’”

Aluko wants younger physicians to know that the long journey to a physician career is worth it. She encourages them to take advantage of all it has to offer.

“Residency can be really tough,” she says. “It can feel like it will ever end, but it will. And after it does, you get the flexibility to think about what you really want to do. Your first job doesn’t have to be your forever job. Your first couple of years post-residency are a time to get to know yourself and your interests—and to really hone your skills as a physician.”

Above all, your physician training is an asset no one can ever take away from you. As Aluko says, “You’ll always have the opportunity to pivot into new roles. If you decide you want to do medicine one day a week and also write a travel blog, that’s a choice you’re free to make. Life is too short to be miserable. You only have one life. Do what you love.”