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Table of Contents    
GUEST COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 5  |  Page : 1276-1278

Considerations for young neurologists/neurosurgeons on how to negotiate a contract in a private hospital


Department of Neurosurgery, Saifee Hospital, Mumbai, Maharashtra, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Dr. Suresh Sankhla
Department of Neurosurgery, Saifee Hospital, Mumbai, Maharashtra, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.241400

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How to cite this article:
Sankhla S, Shah GR. Considerations for young neurologists/neurosurgeons on how to negotiate a contract in a private hospital. Neurol India 2018;66:1276-8

How to cite this URL:
Sankhla S, Shah GR. Considerations for young neurologists/neurosurgeons on how to negotiate a contract in a private hospital. Neurol India [serial online] 2018 [cited 2018 Oct 23];66:1276-8. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1276/241400


One of the most difficult questions in the minds of most younger neurologists and neurosurgeons these days may not be related to the patient care, but reflects a more personal dilemma – where to begin one's career? The issue generally rests on the choices between academia, private practice, and hospital employment. Needless to say, the confusion gets aggravated further with the positives and negative considerations inherent in these options. The fastest growing segment of recruitment for new doctors undoubtedly is the hospital employment. Merritt Hawkins (USA), in their 2012 Review of Physician Recruiting Incentives, reported an 11% rise in the number of physicians in the United States choosing hospital employment from 2004 to 2011.[1] In a survey in 2014, approximately 22.7% of all members of the American Association of Neurologists (AAN) opted for hospital jobs.[2] The trend in India is no different.

Healthcare has become one of the largest sectors in terms of employment and revenue generation in India, comprising hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medical equipment. The corporate hospitals are set to gain due to the rapid growth of health care industry in India. In the current scenario, what is going to come very soon is a more complex and dynamic bonding between the hospital management, physicians, and patients. The volatile and ever-changing economic forces of the corporate world may rock this crucial relationship back and forth in different directions, hereto completely unknown to physicians. The majority of young doctors are unaware of these factors at the beginning of their career, mainly because these aspects are not covered in their specialty training programs. For most doctors, the choice for the hospital employment stems from their own personalities and their drive for independence. A steady pay-cheque and the seemingly lucrative prospect offered by the private hospitals, make the corporate hospital job offers more attractive and almost irresistible to young neurologists or neurosurgeons, who have embarked upon their careers after having passed out from a busy training institute.[3],[4],[5]

In the present scenario of rapidly changing dynamics of the health industry, understanding the intricacies of job prospects in a corporate hospital is very crucial. New job seekers are advised to make their initial selection with care, and are warned of any hastily made decisions that may lead to frequent change of jobs, financial losses and utter frustration. In this article, the authors, based on their own experience, have made an attempt to discuss common issues that a neurologist/neurosurgeon must be aware of before signing the contract of a new assignment. Although, we agree that no solution is more effective than a combination of self-education and a higher level of self-advocacy while making decisions, we hope that this article will provide some insights and guidance to the candidates in making the correct choices.

Young doctors often lack experience in searching for jobs and in handling contracts. The job search should ideally be started early, contrary to the general belief. It should be broad and covering a large number of options to begin with. If one waits too long, confusion and panic can set in, which may force one to accept an offer out of necessity rather than choice. It has been observed that the process is fairly time-consuming, and hence, should be started approximately 12-18 months prior to the end of training to avoid having to make a rushed decision. Unlike in many western countries where the recruitment process is well-established, in India, the job aspirants still face difficulties in identifying job opportunities due to the lack of well-developed recruitment services. Friends and colleagues are usually the most reliable sources of information. Most candidates share job-related information among trainees and employees from other centers. Medical conferences, workshops, and meetings are, in fact, excellent venues of casual but directed information from doctors currently practicing in the setting one is interested in. The Neurological Society of India (NSI) has recently founded the “Private Practitioner's Forum” (PPF), which has its regular meetings to address the problems of the private practitioners in the Neurology and Neurosurgery sectors of India. The forum may be used to help the job aspirants by establishing a countrywide system to list the job opportunities and to ensure a simple and transparent process of selection. Employing physician recruiters or search agencies who can set up meetings with others on the staff is not a common practice in India and should be carried out with extreme caution.

One of the major problems with the young doctors is the lack of the ability to negotiate job contracts. It has been observed that only 20%-25% of physicians negotiate their salaries. Conducting negotiations before signing the contract is extremely important because it directly influences one's future career and prospects. There is always room for negotiation. If one negotiates properly, there are 80% chances that one will get more. One should not allow his/her pay-cheque to dominate the overall package because the salary reflects only one part of the job contract. Personal academic goals, development of practice and goodwill, and the long-term growth plans should also be taken into account. The new doctors should be careful not to indicate that they are comfortable with a certain salary level because that makes later negotiations difficult. Before one is ready to begin negotiations, one is advised to take a personal inventory and review one's current needs, interests and goals correctly.

The contract should have a well-defined and transparent structure for salary and other revenues. There are different modus operandi and varied remuneration structures commonly adapted during signing of the contract. In the first and the most commonly used system, the individual is hired for his/her full-time services on an annual salary of a fixed and mutually agreed-upon amount. There is no other source of revenue besides the salary. The annual or periodic increments, in this case, depend completely on the initial agreement made between the physician and the hospital management. The other system includes a fixed annual salary amount, which is determined by both parties and is usually not very high. In addition to that, further remuneration is considered on the basis of an average revenue generated for a period that varies from 1-3 years. In the third type of financial contract, commonly known as “retainership”, a fixed minimum annual remuneration is decided initially and the revenue generated over and above this amount every month is shared between the doctor and the institution in a ratio ranging from 70:30 to 90:10, respectively. Lastly, there is one more system of financial arrangement in practice in which, the patient is billed by the doctors and the hospital separately for providing their respective services. In a more advanced and complex form of the above system, the neurosciences facility as a whole, or the neurological and neurosurgical services separately, are outsourced and managed by a single specialist or a group of specialists independently, within the same hospital premises.

Every system has its merits and demerits that one has to understand clearly. The fixed annual remuneration system is simple and often more appealing to the new consultants because of its apparently attractive salary structure, at least in the beginning. However, when salary increments do not grow in tandem with the growth in practice over the next few years, it can become a matter of serious disappointment for the newly joined consultants. Generally, the annual increments are estimated to be approximately 35% (the figure includes 25% for one's professional value and a 10% inflation rate). Similarly, retainerships and other similar types of contracts require a full commitment from both the parties, and are at the risk of periodic fluctuations in revenues and temporary set-backs that may cause undue distress. A prior clear discussion on the salary, increments, and other remunerations based on the expected rise in practice and inflation, and the unexpected seasonal variations in revenues can avoid many such problems. Also, a minimum term that ranges between 3 to 5 years should be considered for any contract before it is subjected to termination or alterations, with a clear consent from both the parties.

Most of these remuneration policies revolve around the capabilities of and the revenue generated by the individuals. A newly appointed person has to justify his salary demand by his qualifications, experience, capabilities, and recommendations from the seniors or records from his last employment. The ultimate test for him is to show corresponding revenues that are matching well with his salary, in next 1-3 years. Failing to do so may force the hospital to cut down remunerations accordingly, which may lead to the development of frustration in the newly joined consultants. It is, therefore, advisable to begin with a modest salary, and at the same time, insist on having provisions for periodic increments, which may be based on the individual's ability to develop the centre, or grow individual practice, or both, in the coming years. By doing so, a young doctor can actually avoid unnecessary stress and pressure of being forced to perform better and earn revenue for the hospital at a faster pace than is his own natural speed. Opting for a modest beginning also allows the young consultant to plan and expand the practice gradually and more systematically in the near future. Most hospital managements are also comfortable with this arrangement as it tends to bring down their initial investment significantly.

Negotiation is, thus, a very important part of the job contract. However, before starting the negotiations, the young neurologists or neurosurgeons are advised to carry out self-assessment by analyzing few specific points like the individual's interests and future plans, the hospital's policies and preferences, and the growth potential of practice in that hospital. There should be a complete clarity in their mind on whether monitory benefits will be preferred over job prospects, or vice versa. Although, many people choose to remain in independent practice and prefer an academic growth and job satisfaction over financial and other material benefits, there are others for whom free housing, a job for the spouse, comfortable working hours, and convenient leave arrangements, etc., are equally essential or even more important. Many doctors may be ready to make compromises on their salary increments if they are provided with other incentives like modern equipment, training facilities, education and research funds, and centre building opportunities. All alternatives should be considered and discussed openly in a positive manner while negotiating the terms and conditions with the hospital management. Finally, it is the confidence of the candidate in himself and in his capabilities, together with his experience and willingness to work hard that makes a major impact on his work contract.

The employment contract is actually a trust that has been formed between two parties with the objective of achieving bilateral progress with the help of each other. Once the trust has been established, the newly appointed doctor has total moral responsibility to ensure the smooth running and development of services in that hospital. Therefore, every step taken and every move made should be considered in the benefit of the institution. The working schedule, leave arrangements, legal and medical insurance coverage, and other privileges are more or less standard and can be worked out with the hospital management without any significant hassle if the matters are discussed in the good interest of the hospital.

The issue of appointment of other colleagues is very sensitive and can lead to considerable misunderstandings, distrust, and often, an unpleasant outcome. The need for specialists in sub-specialties like neuroradiology, neurophysiology, neuropathology, neuroanesthesia, neurorehabilitation, and other similar fields is essential for the development of clinical neurosciences in any institute and should really be encouraged. However, hiring more colleagues in one's own specialty is a combined decision taken by the doctors and the hospital management, and should be based on many factors including the nature of the hospital practice, the growth and expansion of the specialty, the availability of specialists, and the future plans of the institution. Ideally, additional recruitment is done with the aim to increase growth of the department, when it is felt that the number of present staff members is inadequate to cope with the work, or there is no staff member qualified to do a particular type of work. It should not always be taken as an indicator of poor performance, nor an indicator of creating more competition or breaking the monopoly. Again, healthy negotiations with the hospital management in the beginning, with clear understanding of the views of both the sides, are extremely important for a steady growth of the individuals and institutions. The contract should also consider an agreement on working in different hospitals, or seeing or managing patients in places other than the main hospital itself. One's negotiations should also aim at leaving oneself with quality time to work at one's own pace…leaving adequate time to focus on academic and personal issues.

There is a saying, “Be committed, not attached. But more importantly know the difference.” One may not be able to cover every situation that arises once the contract has been signed but one can control one's attitude and how one deals with it. A positive attitude and a readiness to move on amicably if the situation so desires, helps to maintain both one's inner dynamism and equanimity.

 
  References Top

1.
Merritt Hawkins. 2012 review of physicians recruiting incentives. Available from: http://www.hfma.org/brg/pdf/2012%20Physician%20Recruiting%20Incentives%20Survey.pdf. [Last accessed on 2018 Sep 04].  Back to cited text no. 1
    
2.
American Association of Neurological Surgeons. 2015 Insight Report. Based on 2014 data and information. Available from: https://www.aan.com/siteassets/home-page/conferences-and-community/member-engagement/learn-about-aan-committees/board-planning/2015-insights-report.pdf. [Last accessed on 2018 Sep 04].  Back to cited text no. 2
    
3.
Gourie-Devi M. Training neurologists in India: Past, present and future. Neurol India 2016;64:602-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Banerji AK. Neurosurgical training and evaluation – Need for a paradigm shift. Neurol India 2016;64:1119-2.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Vilanilam GC, Easwer H V, Menon GR, Karmarkar V. “Magister neurochirurgiae": A 3-year ‘crash course' or a 5-year ‘punctilious pedagogy'?. Neurol India 2017;65:434-7.  Back to cited text no. 5
[PUBMED]  [Full text]  




 

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