Have you made plans yet for after you complete your residency? These third-year residents share their perspectives on the pros and cons of private practice and fellowship, navigating state licensing and insurance companies, and how their residency directors help them with post-residency employment options.
Have you started making your post-residency plans? Are you familiar with the licensure process and examination date of the state where you plan to practice? Each insurance company has an application process that can take a long time. Have you reached out to prospective insurers as well? In your experience, what are the toughest challenges with the stare licensure process and the application process for insurance companies?
Hope Jacoby, DPM, notes she started the process for post-residency plans at the end of her second year of residency and still has not finalized them. After updating her resume/CV and creating a cover letter/letter of intent, Dr. Jacoby started looking into states where she preferred to live and learning the respective state licensure processes. In August of her third residency year, Dr. Jacoby started the state licensure process for two out of the three states she identified as one state wouldn’t accept her application until March of the third residency year.
“Over the course of about four to six weeks, I was collecting paperwork for the application, ordering transcripts and board reports, and of course sending the fees with the completed applications,” recalls Dr. Jacoby.
Alaa Mansour, DPM, notes that the state licensure process can be challenging due to the variation in the rules and regulations for each state. Dr. Jacoby concurs. She adds that some states have board exams, some have later application dates, some require personal essays and some have high fees. Noting that she didn’t know much about the state licensure process until she was submerged in it, Dr. Jacoby said it was difficult staying on top of the process for two states that were completely different.
“(For one state), I had to immediately start completing CMEs, online medical awareness courses and provide renewal fees after three months whereas the other state had minimal requirements after becoming officially licensed,” explains Dr. Jacoby.
Dr. Mansour adds that the instructions on the state licensure websites are often not clear. He recommends calling the office and speaking with an administrator. Dr. Mansour emphasizes frequent follow-up and beginning the licensure process as soon as you know the state where you will work.
“This is important because when it comes time to apply for insurance companies, processing can take up to 120 days,” maintains Dr. Mansour. “The greatest challenge is the amount of time it takes to gather all the requirements and wait for the license to be granted. The whole process can take several months and requires constant communication with the office of licensing, usually entailing weekly phone calls and e-mails to make sure all documents have been received.”
Dr. Mansour recommends using tracking with any mailed items. He also reminds residents to double check that they have sent mandatory fees and notes that many states require an additional fee for license verification.
Overall, the challenges Dr. Jacoby has noticed with the state licensure process are as follows:
- high fees on a resident salary;
- a multitude of paperwork that needs to be signed and sent from different organizations and people to the state board, and not knowing if it arrived; and
- the amount of time it takes for the board to collect every last piece.
“I would advise three months from start to finish for state licensing,” says Dr. Jacoby.
In regard to insurance companies, Dr. Jacoby notes she has not researched insurance plans. She notes that she has heard from recently graduated residents that the future employer has some on staff to help guide you through the insurance company process at the time of hire. Dr. Mansour adds that many private practices have a coordinator who handles the application process for insurance companies as well as hospital credentialing, which “reduces the amount of stress on the new graduate.” He points out that applying for most insurance companies requires two applications and accordingly, double the work.
“First, you will require a Council for Affordable Quality Healthcare (CAQH) account, which is an online database that stores provider information and grants insurance companies access to this information,” explains Dr. Mansour. “You will also need an initial application to insurance companies. A majority of insurance companies require 90-120 days after approval of the initial application before you can see any patients.”
In regard to malpractice insurance, Dr. Mansour says if you are joining a private practice, it is likely that you will be insured by the same company as the group. If you are opening your own practice, Dr. Mansour says you’ll need to call around to get the best deal. “Keep in mind the starting rate for a new graduate and ask for the expected rate in five to 10 years,” advises Dr. Mansour.
What are your thoughts regarding whether to apply for a fellowship, start your own practice or join an existing practice?
Dr. Mansour says residents should begin to contemplate their post-residency plans during the final months of the first residency year. During this time, Dr. Mansour notes one should keep an eye out for job openings, private practices for sale or a location that may be conducive to setting up a new practice.
Paxon Riding, DPM, began looking into fellowship opportunities during his second year of residency. Dr. Riding says he liked the idea of the extra training that a fellowship would provide as well as the enhanced credentialing it offers in order to make one more competitive for coveted jobs after the fellowship is complete. He notes that he started looking for fellowship opportunities during his third year of residency but stopped when a dream job became available.
From Dr. Jacoby’s perspective, fellowships are for people who did not get enough surgical volume exposure and feel another year would be beneficial, or those who want to focus on a specific aspect of podiatry (Charcot reconstruction/limb deformity for example) and go into a specialized practice. With the latter, Dr. Jacoby believes there are only a handful of well-known fellowships that can make a difference in terms of future employment.
Dr. Jacoby notes she is “not totally convinced” that being fellowship-trained correlates with working with orthopedic groups, getting a better job or getting better reimbursement. She does feel that previously offered fellowships (i.e. the AO fellowship in Switzerland no longer offered to DPMs) may have been beneficial in advancing surgical skills and possibly facilitating higher reimbursement in the future. That said, Dr. Jacoby notes that she is not interested in pursuing a fellowship after residency.
After residency, Dr. Mansour does plan to pursue a surgically-focused fellowship with a large private practice group in Indianapolis. He notes that the additional year of specialized training can be surgical, clinical, wound care-oriented or research-oriented.
“Fellowship is a great opportunity that can offer you resources, guidance and professional networks to pursue goals that you might not otherwise be able to achieve,” maintains Dr. Mansour.
He notes there are many fellowships available and it is competitive. One should keep in mind why they are applying for a specific fellowship and what he or she hopes to get out of it, according to Dr. Mansour. He recommends reaching out to a current fellow at a fellowship you are interested in and setting up a visit. At the visit, Dr. Mansour suggests asking the fellow about the focus of the fellowship, what kind of volume can be expected and what type of employment opportunities the fellow is looking at as a result of doing the fellowship.
In regard to joining a private practice, Dr. Mansour says this is usually regarded as a good starting point because the business foundation and referral sources are already established. Other benefits are shared overhead costs, having doctors that work with you and working with experienced colleagues whom you can rely on for help and mentorship, according to Dr. Mansour.
Dr. Riding says he didn’t think starting his own practice from scratch after residency was feasible financially. Accordingly, he applied for various associate positions and visited several of those practices. However, Dr. Riding felt that most of the practices he visited did not place enough value for incoming DPMs and notes that he did not feel comfortable with any of the offers he received prior to a most recent job offer in Idaho.
According to Dr. Jacoby, joining a practice versus starting your own comes down to three things: money, time and location. For most graduating residents saddled with podiatry school and undergraduate loans, Dr. Jacoby says “the idea of taking out another chunk of change with reimbursement at best being three to six months later is risky.” If you have five or so years to put into the practice management aspect other than caring for patients, she notes that can be a pro for starting your own practice. In regard to location, Dr. Jacoby says if you are being offered a lease, own property or are planning to practice in a non-podiatry saturated area of the country where business would be booming the moment you arrive in town, then starting a new practice might make sense. Otherwise, Dr. Jacoby says the prevailing course for folks coming out of residency is to join an existing practice, save up, find the right location and work toward owning one’s own practice if that is the ultimate goal.
Dr. Mansour concurs that starting your own practice can be rewarding but risky.
“Starting your own practice requires someone who is goal-oriented, highly creative and business-minded,” notes Dr. Mansour. “It requires a lot more work, patience and motivation.”
Does your residency director help you with your next important decision? Do you have a letter of recommendation on file? Does your residency director review contracts and job offers?
Dr. Mansour notes he is grateful for his residency director, Lawrence Fallat, DPM, FACFAS, who offers insight, advice and directs residents to possible hiring opportunities. He adds that Dr. Fallat reviews contracts if residents ask and makes suggestions on specifics to focus on and possibly negotiate.
Dr. Jacoby says her residency director, Samuel Mendicino, DPM, FACFAS, forwards job opportunities he receives via e-mail and is accommodating when approached with questions. In addition to learning invaluable skills in surgery, practice management, etc., Dr. Riding credits his residency director, David Bernstein, DPM, FACFAS, with writing numerous letters of recommendation and speaking directly with several of Dr. Riding’s potential employers.
“On more than one occasion, I was immediately offered the job after submitting my residency director’s letter of recommendation,” adds Dr. Riding.
Drs. Jacoby and Mansour have found that references seem to be more valued by prospective employers than letters of recommendation. Dr. Mansour has observed that many private practices will ask for references and call them prior to scheduling an interview. Regardless, Dr. Mansour says it can only help graduating residents to have two letters of recommendation ready and available upon request. He adds that alumni of the residency program can be very helpful and a great resource when it comes to all aspects of the process for obtaining post-residency employment.
Dr. Jacoby is a Chief Resident at the Foot & Ankle Surgical Residency Program at West Houston Medical Center (previously Harris County) in Houston, Texas.
Dr. Mansour is the Chief Resident at the Podiatric Foot and Ankle Surgical Residency at Beaumont Hospital-Wayne in Wayne, Mich.
Dr. Riding is a third-year resident with the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa.
Dr. Bernstein is the Director of the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.