I was just handed a HUGE negotiating chip. Help me cash it in.
June 11, 2016 3:50 AM Subscribe
I am on the verge of quitting my job over excessive work, low pay, etc. I just discovered that a project I alone have Implemented is bringing in a huge unexpected financial windfall for my company. Help me translate this into more sustainable working conditions, for I am a well meaning sucker who is bad at negotiating and business confrontation. Extended details inside.
Long story. About seven years ago, I moved from a leadership position at a traditional private medical practice to a far more personally rewarding but much lower paying job at a community health center. And for years, I loved it. Loved my partners, found the work intensely challenging, interesting, and deeply satisfying. I work walking distance from home. I was freed from the enormously frustrating burden of dealing with health insurance companies finding it far easier to get things done with Medicare, Medicaid, and charity. Despite the pay cut, I was pushing myself far more than ever, for patients who were grateful and an organization that appreciated my work.
Two years ago, the Affordable Care Act (which is no question a huge step forward for patients and the floundering US health care system) was enacted, and my nonprofit organization full of well meaning people with their hearts in the right place was pushed into the uber competitive world of private insurance, an environment they are completely unfamiliar with and one that I have had extensive negative experience with. Overnight, paperwork quadrupled, management became far more fixated on revenue and productivity at the expense of doing the right thing for patients and worker happiness. I have no leadership position here and am just a worker bee suffering under small minded middle managers carrying out orders from central HQ.
Last year a former med school colleague and highly respected academic physician approached our organization with a proposal to join a large grant to start implementing hepatitis C testing and treatment in primary care and specifically requested that I lead this project. I did not initiate this but when the medical director approached me about it, I enthusiastically accepted as we have a huge number of IV drug abusers with hep C and we all have seen dozens of our patients die from cirrhosis. In the last two years treatments have made this an entirely treatable disease but working up the patients and selecting/managing their medication is complex and access to these treatments has meant referral to specialty clinics with long waiting lists and high costs. I accepted this project with the very very clear understanding that I was in no position to increase my work hours. Not a problem I was told. I'd have protected time and I'd be able to hire an assistant. A contract was negotiated and things moved forward. Unfortunately, the project turned out to be far more work than was anticipated. I spent countless hours getting up to speed attending conferences and doing home study in order to gain competence. I had to train my assistant in data management and education. I attended regular grant meetings and writing reports. I gave talks to my colleagues and recruited patients and regularly dropped everything to respond to questions from the other doctors. All while maintaining my already full clinical care responsibilities. It quickly became apparent that we were not getting anywhere near enough support and protected time to get this up and running. My assistant and I spent a year requesting more support and we were turned down every single time we asked for this, with the explanation that our financial margins were way too thin it it was absolutely critical that I continue to crank out as many patient visits as possible. My already declining work life balance went into the toilet and I became profoundly anxious and depressed trying to make this happen. I started seeing a counselor and a psychiatrist just to cope with the long hours and on one occasion ended up being taken by ambulance to the hospital after a particularly deep mental decompensation. Finally, a few months ago, my assistant quit in frustration. Despite all this, I persevered, as my personal and professional reputation was at stake. 6 months ago, I started my first patients on treatment and we've seen a dozen or more cures by now. Lives saved.
Because we still had a contractual obligation to continue to report data when my assistant left, the task fell to a high level administrator. Within one week of this, I was informed by the leadership that actually we really weren't really getting enough support to do this project and that we'd be pulling out of the grant. *After* I'd spent a year saying so and *after* I'd done the major amount of work getting things up and running. (In fact, I was informed of this while on vacation in London and "would I mind putting together some data for the leadership council before they made their final decision on Monday" and that was how I spent one of my days in London.)
But the thing is, I've continued to see and treat these patients because it's unethical to stop -- most of these patients can't get in anywhere else, and everyone sees me as the local expert on this and we literally have thousands of patients at risk for hospitalization and dying from hepatitis C. And I really like doing this. And a lot of the hard stuff has now been done.
But my family life has continued their deteriorate and I reached a moment last month after another grueling 60 hour week where I cried "uncle!" and admitted to myself I was done. The job was too hard and I've become completely disillusioned with medicine and I just refuse to do this anymore. I informed my clinic manager and at my annual review with my medical director which was conincidentally the following week, I remained firm. Not only were they not protecting me but I've worked in enough medical settings to know I'm not going through be happier elsewhere. I'm out. Neither of these people are really powerful enough to offer substantial changes in my job but neither offered to go to bat for me either.
Unfortunately, I still have $100K in student loans, a mortgage, and 2 kids in private school so walking away is not something I can just do next week. But I'm figuring out my options.
In the meantime, I scheduled a meeting with the CEO with whom I have a generally friendly relationship with and this is happening on Monday. Just to give my perspective and test the waters to see if they'll really let me walk. In preparation for this, I was crunching some numbers and talking to our pharmacist and discovered something astonishing. In just six months, and with very little recruiting for patients, I discovered that due to activities done largely on my own time I alone caused the organization to accumulate $500,000 they neither planned for nor budgeted. Most of this is going to pharmacy which is a different department from me and my guess is that people in the business office looking at spread sheets have not yet connected this windfall to my activities. When I leave, there is no one else who will easily come in and maintain this revenue and it will stop. Furthermore, I'm just getting started and anticipate ramping up quite a bit more if I am able to.
So, I feel like I've just been handed a pretty strong bargaining chip, no? The problem is, I have a terrible head for business and I am a terrible negotiator. I can't even haggle prices down at the market in places like India and Mexico where you are supposed to do so. Money is not a strong enough motivator for me personally to really go after what I want and I stupidly assume everyone operates with the best intentions like me. And I'm not sure what I really want, except to work a lot less and make a little more I suppose. But I think I need to request something more specific, right?
So help me Mefi. How do you bargain hard for something with someone you have a collegial relationship with? And what key things do I need to do in 2 days when operating like this feels completely unnatural to me?
I should say that I really am prepared to walk away and I'm working my network and I want to make that clear to my CEO but I don't have anything in hand and can't really follow through on the threat right away. (There is no way they will fire me. It's too hard to replace a midcareer physician with a full practice and I'm the only person in our organization who's ever made the annual list of Seattle's Top Doctors, and I've got my hands in way too many projects.)
Long story. About seven years ago, I moved from a leadership position at a traditional private medical practice to a far more personally rewarding but much lower paying job at a community health center. And for years, I loved it. Loved my partners, found the work intensely challenging, interesting, and deeply satisfying. I work walking distance from home. I was freed from the enormously frustrating burden of dealing with health insurance companies finding it far easier to get things done with Medicare, Medicaid, and charity. Despite the pay cut, I was pushing myself far more than ever, for patients who were grateful and an organization that appreciated my work.
Two years ago, the Affordable Care Act (which is no question a huge step forward for patients and the floundering US health care system) was enacted, and my nonprofit organization full of well meaning people with their hearts in the right place was pushed into the uber competitive world of private insurance, an environment they are completely unfamiliar with and one that I have had extensive negative experience with. Overnight, paperwork quadrupled, management became far more fixated on revenue and productivity at the expense of doing the right thing for patients and worker happiness. I have no leadership position here and am just a worker bee suffering under small minded middle managers carrying out orders from central HQ.
Last year a former med school colleague and highly respected academic physician approached our organization with a proposal to join a large grant to start implementing hepatitis C testing and treatment in primary care and specifically requested that I lead this project. I did not initiate this but when the medical director approached me about it, I enthusiastically accepted as we have a huge number of IV drug abusers with hep C and we all have seen dozens of our patients die from cirrhosis. In the last two years treatments have made this an entirely treatable disease but working up the patients and selecting/managing their medication is complex and access to these treatments has meant referral to specialty clinics with long waiting lists and high costs. I accepted this project with the very very clear understanding that I was in no position to increase my work hours. Not a problem I was told. I'd have protected time and I'd be able to hire an assistant. A contract was negotiated and things moved forward. Unfortunately, the project turned out to be far more work than was anticipated. I spent countless hours getting up to speed attending conferences and doing home study in order to gain competence. I had to train my assistant in data management and education. I attended regular grant meetings and writing reports. I gave talks to my colleagues and recruited patients and regularly dropped everything to respond to questions from the other doctors. All while maintaining my already full clinical care responsibilities. It quickly became apparent that we were not getting anywhere near enough support and protected time to get this up and running. My assistant and I spent a year requesting more support and we were turned down every single time we asked for this, with the explanation that our financial margins were way too thin it it was absolutely critical that I continue to crank out as many patient visits as possible. My already declining work life balance went into the toilet and I became profoundly anxious and depressed trying to make this happen. I started seeing a counselor and a psychiatrist just to cope with the long hours and on one occasion ended up being taken by ambulance to the hospital after a particularly deep mental decompensation. Finally, a few months ago, my assistant quit in frustration. Despite all this, I persevered, as my personal and professional reputation was at stake. 6 months ago, I started my first patients on treatment and we've seen a dozen or more cures by now. Lives saved.
Because we still had a contractual obligation to continue to report data when my assistant left, the task fell to a high level administrator. Within one week of this, I was informed by the leadership that actually we really weren't really getting enough support to do this project and that we'd be pulling out of the grant. *After* I'd spent a year saying so and *after* I'd done the major amount of work getting things up and running. (In fact, I was informed of this while on vacation in London and "would I mind putting together some data for the leadership council before they made their final decision on Monday" and that was how I spent one of my days in London.)
But the thing is, I've continued to see and treat these patients because it's unethical to stop -- most of these patients can't get in anywhere else, and everyone sees me as the local expert on this and we literally have thousands of patients at risk for hospitalization and dying from hepatitis C. And I really like doing this. And a lot of the hard stuff has now been done.
But my family life has continued their deteriorate and I reached a moment last month after another grueling 60 hour week where I cried "uncle!" and admitted to myself I was done. The job was too hard and I've become completely disillusioned with medicine and I just refuse to do this anymore. I informed my clinic manager and at my annual review with my medical director which was conincidentally the following week, I remained firm. Not only were they not protecting me but I've worked in enough medical settings to know I'm not going through be happier elsewhere. I'm out. Neither of these people are really powerful enough to offer substantial changes in my job but neither offered to go to bat for me either.
Unfortunately, I still have $100K in student loans, a mortgage, and 2 kids in private school so walking away is not something I can just do next week. But I'm figuring out my options.
In the meantime, I scheduled a meeting with the CEO with whom I have a generally friendly relationship with and this is happening on Monday. Just to give my perspective and test the waters to see if they'll really let me walk. In preparation for this, I was crunching some numbers and talking to our pharmacist and discovered something astonishing. In just six months, and with very little recruiting for patients, I discovered that due to activities done largely on my own time I alone caused the organization to accumulate $500,000 they neither planned for nor budgeted. Most of this is going to pharmacy which is a different department from me and my guess is that people in the business office looking at spread sheets have not yet connected this windfall to my activities. When I leave, there is no one else who will easily come in and maintain this revenue and it will stop. Furthermore, I'm just getting started and anticipate ramping up quite a bit more if I am able to.
So, I feel like I've just been handed a pretty strong bargaining chip, no? The problem is, I have a terrible head for business and I am a terrible negotiator. I can't even haggle prices down at the market in places like India and Mexico where you are supposed to do so. Money is not a strong enough motivator for me personally to really go after what I want and I stupidly assume everyone operates with the best intentions like me. And I'm not sure what I really want, except to work a lot less and make a little more I suppose. But I think I need to request something more specific, right?
So help me Mefi. How do you bargain hard for something with someone you have a collegial relationship with? And what key things do I need to do in 2 days when operating like this feels completely unnatural to me?
I should say that I really am prepared to walk away and I'm working my network and I want to make that clear to my CEO but I don't have anything in hand and can't really follow through on the threat right away. (There is no way they will fire me. It's too hard to replace a midcareer physician with a full practice and I'm the only person in our organization who's ever made the annual list of Seattle's Top Doctors, and I've got my hands in way too many projects.)
Also, I have not thought that answer up there through 100%, so I want to chew on it for a bit before saying it's exactly what I would recommend. Just consider it food for thought right now.
posted by Stewriffic at 4:30 AM on June 11, 2016
posted by Stewriffic at 4:30 AM on June 11, 2016
Yeah, it really doesn't matter how much leverage you have if you're not sure what you want, so figuring that out should be the priority.
Also, it's been my experience that most company cultures are poor at preventing burn out from passionate employees that care too much. The reason I bring this up is that you seem to expect your work culture to be able to carve out responsibilities to match a reasonable workload, and you provide no evidence they can do that. Which makes me worried for you that even if you negotiated for less work, the actual load might again grow past your boundaries again.
But, I am in a completely unrelated field so take my experiences with quite a few grains of salt.
posted by forforf at 6:18 AM on June 11, 2016 [1 favorite]
Also, it's been my experience that most company cultures are poor at preventing burn out from passionate employees that care too much. The reason I bring this up is that you seem to expect your work culture to be able to carve out responsibilities to match a reasonable workload, and you provide no evidence they can do that. Which makes me worried for you that even if you negotiated for less work, the actual load might again grow past your boundaries again.
But, I am in a completely unrelated field so take my experiences with quite a few grains of salt.
posted by forforf at 6:18 AM on June 11, 2016 [1 favorite]
Response by poster: That's completely valid forforf and something I've been considering. I actually did cut my FTE slightly about two years ago and that's exactly what happened. But I've been working with my counselor on setting work limits, so who knows? But for now, I just want to know how to deal with my CEO to see if I can try to set something up that might be sustainable.
In terms of what I am thinking of asking for is something like four hours of protected project time per week (in lieu of four hours of patient contact which translates to about 8 hours per week of actual work) and a 5-10% pay raise.
posted by Slarty Bartfast at 7:33 AM on June 11, 2016
In terms of what I am thinking of asking for is something like four hours of protected project time per week (in lieu of four hours of patient contact which translates to about 8 hours per week of actual work) and a 5-10% pay raise.
posted by Slarty Bartfast at 7:33 AM on June 11, 2016
Would getting another assistant help? Assuming their salary could draw partly from the $500k, perhaps someone with more experience/background whom you'd need to train less (and thus pay more) would be easier. My understanding is that there aren't huge numbers of jobs for MPH folks out there (sadly) so maybe someone with that background?
posted by needs more cowbell at 7:35 AM on June 11, 2016
posted by needs more cowbell at 7:35 AM on June 11, 2016
Response by poster: Hiring an assistant is on the table, but again, my problem is how to work with a CEO whose position now is (or may be) "There's no problem here, you're getting the same deal as all the other employees here. I haven't heard about this 500,000 dollar thing. Why should you get special treatment? Everyone's struggling with the increased burden of the ACA and they're not calling for meetings with me."
posted by Slarty Bartfast at 7:45 AM on June 11, 2016
posted by Slarty Bartfast at 7:45 AM on June 11, 2016
Wow, a lot to grok but it sound like doc's need either (hollywood style) agents or a good union. Unfortunately unless you have control of the 500k it may not be your chip but a chip donated to the house (whoever controls the moolah).
Brinksmanship is pretty scary but can work, but in ANY negotiation you MUST be ready to walk away or the other side gots you by the short hairs.
Get ready for the walk and ask for double (at least) of what you really want.
Give them lots of face saving tools, bundle up many arguments ($500k now, $5Mil on the next contract with your ideas) (yes lie, make stuff up, tell big Big BIG stories) let them dream. But be ready to walk.
Good luck, keep up the good work.
posted by sammyo at 7:47 AM on June 11, 2016 [2 favorites]
Brinksmanship is pretty scary but can work, but in ANY negotiation you MUST be ready to walk away or the other side gots you by the short hairs.
Get ready for the walk and ask for double (at least) of what you really want.
Give them lots of face saving tools, bundle up many arguments ($500k now, $5Mil on the next contract with your ideas) (yes lie, make stuff up, tell big Big BIG stories) let them dream. But be ready to walk.
Good luck, keep up the good work.
posted by sammyo at 7:47 AM on June 11, 2016 [2 favorites]
From a negotiating perspective, the additional $500k of revenue (on top of the grant) is a strong point. You're a doctor, not the firm's accountant, so it's not your job to determine how much of that is profit. But it's exactly the sort of metric that people are encouraged to bring up in job interviews or performance evaluations as evidence of a job well done.
That said, is a 5-10% increase in salary and a modest change in hours (which, let's be real, will likely not be honored even if they allow it) be enough to make you happier? Why not ask for something more substantial, like significantly reducing your regular client hours to see more hepatitis patients? Go to part time?
posted by stowaway at 8:57 AM on June 11, 2016
That said, is a 5-10% increase in salary and a modest change in hours (which, let's be real, will likely not be honored even if they allow it) be enough to make you happier? Why not ask for something more substantial, like significantly reducing your regular client hours to see more hepatitis patients? Go to part time?
posted by stowaway at 8:57 AM on June 11, 2016
Your strongest negotiating point is that you are fully, 1000%, prepared to walk unless X happens.
So prepare yourself for that and truly be 1000% prepared to do it.
In fact, given your description above, I would give strong consideration to walking even IF X happens. The X you outline (5-10% raise & 4 hours protected time) would not be **nearly** enough to make me want to stay in such a situation. Personally I would up the asks *considerably*. Ask for what *you* want and need, not what you think they will be likely to give.
FYI student loans can always be pegged to your current income and as of recent developments, can often be forgiven if you have spent 10 years working for some kind of public service organization. If your current employer is a 501c3 those employment years will certainly count (if your student loan is eligible; read the page above).
My point is, nothing you outline above precludes you stepping out of your current job and into something far, far more manageable. I have almost $100K in student debt and I work for a crappy low-paying nonprofit (and before that, a crappy even far-lower-paying academic job). It can be done.
Figure out every contingency, how you will handle everything if you quit this job, and absolutely be prepared to walk away. That is your strongest negotiating position and guarantees you will be happier than you are now whatever way the negotiation goes.
When you are inside a situation like that, it seems impossible to get out of it. But it's not. Be completely prepared to walk away, and be assured that walking away--maybe not abruptly, tomorrow, but giving yourself a reasonable period of a few weeks or so to prepare--will almost certainly be far, far better for you in the long run than the current situation. When you look back at this point 6 months or a year in the future, you'll be astonished that you ever stuck it out so long.
posted by flug at 8:59 AM on June 11, 2016 [5 favorites]
So prepare yourself for that and truly be 1000% prepared to do it.
In fact, given your description above, I would give strong consideration to walking even IF X happens. The X you outline (5-10% raise & 4 hours protected time) would not be **nearly** enough to make me want to stay in such a situation. Personally I would up the asks *considerably*. Ask for what *you* want and need, not what you think they will be likely to give.
FYI student loans can always be pegged to your current income and as of recent developments, can often be forgiven if you have spent 10 years working for some kind of public service organization. If your current employer is a 501c3 those employment years will certainly count (if your student loan is eligible; read the page above).
My point is, nothing you outline above precludes you stepping out of your current job and into something far, far more manageable. I have almost $100K in student debt and I work for a crappy low-paying nonprofit (and before that, a crappy even far-lower-paying academic job). It can be done.
Figure out every contingency, how you will handle everything if you quit this job, and absolutely be prepared to walk away. That is your strongest negotiating position and guarantees you will be happier than you are now whatever way the negotiation goes.
When you are inside a situation like that, it seems impossible to get out of it. But it's not. Be completely prepared to walk away, and be assured that walking away--maybe not abruptly, tomorrow, but giving yourself a reasonable period of a few weeks or so to prepare--will almost certainly be far, far better for you in the long run than the current situation. When you look back at this point 6 months or a year in the future, you'll be astonished that you ever stuck it out so long.
posted by flug at 8:59 AM on June 11, 2016 [5 favorites]
Slarty--
We have somewhat similar career trajectories and interests, I think. (I have been wrestling with getting a plan for HCV treatment up and running at my practice, and would be interested in emailing with you on that subject at another time, but that's not what we're talking about here.)
I'm currently trying to help my best friend, who is FP at an FQHC on the East Coast, with a similar situation.
You do have a big bargaining chip, and the fact that you are the only physician doing the things you are doing is going to be a big part of it. They can certainly argue that there needs to be parity between physicians, but the fact is that your role is not the same as those others. Your time and support needs are different from the other physicians for X, Y, and Z reasons and that is why you should get A, B, and C resources. BUT you will need to be able to articulate it in a convincing way.
your other big bargaining chip is the fact that you're just about ready to walk. It takes time and costs money to get a new physician up and running and they will lose a lot in that process. What's the turnover like at your practice?
It sounds like your leadership is not really in touch with the amount of time you're spending on these things, nor with the benefits that they are bringing. I know that business is not really the forte for most physicians but you need to be able to lay out a compelling financial case for whatever you're asking. And forforf is right, you need to be able to articulate exactly what you want in order to make your case for it. Is it an additional half day of admin time? An additional full day? Someone to handle paperwork that doesn't require an MD? (Getting a care manager who manages all our home care orders and DME along with things like disabled parking permits and meals on wheels requests freaking changed my life. In addition the faxes in our inbox, instead of being full of cover sheets that say THIRD REQUEST, now say things like "Thanks [care manager]! We appreciate your help!" which has intangible benefits when we have to do things like request extra services for difficult patients).
The other pattern that is common at FQHCs is that no one really knows how to bill in a sophisticated way and so they end up churning endless 99213s and 99214s and trying to generate revenue with volume alone. Are you guys billing for home care order review? Hospital follow up? Are you using the add-on codes for depression and alcohol screening, tobacco and cardiovascular counseling? I know you're doing that stuff, are you getting paid for it? Medicaid differs in their willingness to pay for this stuff state by state but we manage to eke an extra thousand a month out of it at our very small practice. Can you make an argument for doing more of this and using the extra revenue to pay for additional support?
If you need to postpone your meeting with the CEO to get clarity on some of these questions, I would encourage you to do that. My experience has been that you get one shot to make a really compelling case for this stuff.
Please feel free to MeMail if you want to bounce some other ideas around.
Finally--I'm glad you're doing something about your work-life balance. Physician burnout is so common and so awful. I switched jobs about a year ago (due to a move) and even though I really loved what I was doing before, I was very, very tired and I didn't even realize it at the time. But I had these really ambitious plans for academic and administrative work at my new job and instead it took literally a year before I was able to do anything except handle my clinical responsibilities, spend time with my family, and sleep. I finally feel like my mental resources are back to the point where I can take additional stuff on, but it's taken a surprising amount of time to fill the well back up.
posted by The Elusive Architeuthis at 9:08 AM on June 11, 2016 [7 favorites]
We have somewhat similar career trajectories and interests, I think. (I have been wrestling with getting a plan for HCV treatment up and running at my practice, and would be interested in emailing with you on that subject at another time, but that's not what we're talking about here.)
I'm currently trying to help my best friend, who is FP at an FQHC on the East Coast, with a similar situation.
You do have a big bargaining chip, and the fact that you are the only physician doing the things you are doing is going to be a big part of it. They can certainly argue that there needs to be parity between physicians, but the fact is that your role is not the same as those others. Your time and support needs are different from the other physicians for X, Y, and Z reasons and that is why you should get A, B, and C resources. BUT you will need to be able to articulate it in a convincing way.
your other big bargaining chip is the fact that you're just about ready to walk. It takes time and costs money to get a new physician up and running and they will lose a lot in that process. What's the turnover like at your practice?
It sounds like your leadership is not really in touch with the amount of time you're spending on these things, nor with the benefits that they are bringing. I know that business is not really the forte for most physicians but you need to be able to lay out a compelling financial case for whatever you're asking. And forforf is right, you need to be able to articulate exactly what you want in order to make your case for it. Is it an additional half day of admin time? An additional full day? Someone to handle paperwork that doesn't require an MD? (Getting a care manager who manages all our home care orders and DME along with things like disabled parking permits and meals on wheels requests freaking changed my life. In addition the faxes in our inbox, instead of being full of cover sheets that say THIRD REQUEST, now say things like "Thanks [care manager]! We appreciate your help!" which has intangible benefits when we have to do things like request extra services for difficult patients).
The other pattern that is common at FQHCs is that no one really knows how to bill in a sophisticated way and so they end up churning endless 99213s and 99214s and trying to generate revenue with volume alone. Are you guys billing for home care order review? Hospital follow up? Are you using the add-on codes for depression and alcohol screening, tobacco and cardiovascular counseling? I know you're doing that stuff, are you getting paid for it? Medicaid differs in their willingness to pay for this stuff state by state but we manage to eke an extra thousand a month out of it at our very small practice. Can you make an argument for doing more of this and using the extra revenue to pay for additional support?
If you need to postpone your meeting with the CEO to get clarity on some of these questions, I would encourage you to do that. My experience has been that you get one shot to make a really compelling case for this stuff.
Please feel free to MeMail if you want to bounce some other ideas around.
Finally--I'm glad you're doing something about your work-life balance. Physician burnout is so common and so awful. I switched jobs about a year ago (due to a move) and even though I really loved what I was doing before, I was very, very tired and I didn't even realize it at the time. But I had these really ambitious plans for academic and administrative work at my new job and instead it took literally a year before I was able to do anything except handle my clinical responsibilities, spend time with my family, and sleep. I finally feel like my mental resources are back to the point where I can take additional stuff on, but it's taken a surprising amount of time to fill the well back up.
posted by The Elusive Architeuthis at 9:08 AM on June 11, 2016 [7 favorites]
Disclaimer: I'm not a good negotiator. I just like being straightforward.
It seems to me that negotiation is a lot easier in your situation. Specifically, you are completely ready to walk, and you prefer that option to the status quo. Therefore, you don't need to worry much about negotiation tactics, brinkmanship, etc. You can just go in and be completely straightforward:
And make sure x, y, and z are solid improvements that you can get in writing with no wiggle-room and that will make a substantial difference in your environment. Your description sounds bad enough that a few small concessions might feel nice for a bit but lead you right back to the same situation. So make sure you're asking for enough to really make it worthwhile to stay.
Provide a very simple choice for them, between A) the costs of you leaving and B) the costs of retaining you. Make sure that in your analysis, the balance between those two looks in favor of retaining you, so you know you're not completely off base, but then let them make the call.
Let the CEO argue all she/he wants about how everyone else is in the same boat, etc. It doesn't matter. The situation doesn't work for you. You're asking for what you need to stay there. It's their call to provide that or not.
In the end, "If you can make this better than my other options, I will stay [and you get X]. If you can't, I will leave [and you lose X]."
Where negotiation gets difficult, for me anyway, is when it's not based on positioning against alternatives. Just trying to convince someone that granting your request is "right" based on appeals to fairness, standards, and so on is tricky. You're not doing that, though.
I was in the Grand Bazaar in Istanbul once (tourist-trap haggle-central), and I was looking at something I thought was attractive but didn't have a huge desire to own. The shopkeeper named a price that was well above anything I would want to pay for it, so I said no thanks. He proceeded to lower the price as I kept saying no thanks. Eventually, he asked how much I would pay for it. I told him honestly what it was worth to me. He found my price ridiculous. So I didn't buy it. No problem. Simple.
In another shop, there was a set of bowls I did want. The starting price was in a reasonable range for me that time, but of course I still did haggle. That's when it got unpleasant. There was a range of prices acceptable to both of us, and we both just wanted to get it as far toward "our" end of the range as possible. Based on what? Force of will and vague guesses as to the probability the other side would walk? Not fun. (And the damn bowls chip like crazy.)
But you're in the first situation. Keep it simple.
posted by whatnotever at 9:40 AM on June 11, 2016 [5 favorites]
It seems to me that negotiation is a lot easier in your situation. Specifically, you are completely ready to walk, and you prefer that option to the status quo. Therefore, you don't need to worry much about negotiation tactics, brinkmanship, etc. You can just go in and be completely straightforward:
- The current situation is untenable for you, and you intend to leave if nothing changes.
- If you leave, [clear, factual, specific consequences for the organization].
- If [x, y, and z] are changed, you will stay.
And make sure x, y, and z are solid improvements that you can get in writing with no wiggle-room and that will make a substantial difference in your environment. Your description sounds bad enough that a few small concessions might feel nice for a bit but lead you right back to the same situation. So make sure you're asking for enough to really make it worthwhile to stay.
Provide a very simple choice for them, between A) the costs of you leaving and B) the costs of retaining you. Make sure that in your analysis, the balance between those two looks in favor of retaining you, so you know you're not completely off base, but then let them make the call.
Let the CEO argue all she/he wants about how everyone else is in the same boat, etc. It doesn't matter. The situation doesn't work for you. You're asking for what you need to stay there. It's their call to provide that or not.
In the end, "If you can make this better than my other options, I will stay [and you get X]. If you can't, I will leave [and you lose X]."
Where negotiation gets difficult, for me anyway, is when it's not based on positioning against alternatives. Just trying to convince someone that granting your request is "right" based on appeals to fairness, standards, and so on is tricky. You're not doing that, though.
I was in the Grand Bazaar in Istanbul once (tourist-trap haggle-central), and I was looking at something I thought was attractive but didn't have a huge desire to own. The shopkeeper named a price that was well above anything I would want to pay for it, so I said no thanks. He proceeded to lower the price as I kept saying no thanks. Eventually, he asked how much I would pay for it. I told him honestly what it was worth to me. He found my price ridiculous. So I didn't buy it. No problem. Simple.
In another shop, there was a set of bowls I did want. The starting price was in a reasonable range for me that time, but of course I still did haggle. That's when it got unpleasant. There was a range of prices acceptable to both of us, and we both just wanted to get it as far toward "our" end of the range as possible. Based on what? Force of will and vague guesses as to the probability the other side would walk? Not fun. (And the damn bowls chip like crazy.)
But you're in the first situation. Keep it simple.
posted by whatnotever at 9:40 AM on June 11, 2016 [5 favorites]
It seems like one of the important issues here is that you're not just a staff physician. You're a manager of a major important program, and what you should ask for is to have your title and salary change to be commensurate with your responsibilities. You don't even have to walk away. You can just say, "I am going to stick to my work with patients and will not get involved in any other initiatives." Continue working with the remaining patients from the study insofar as professional ethics and good health practices requires you to, but remind the CEO that if you're going to be paid like a staff physician, you duties should reflect that.
That said, when you say,
Unfortunately, I still have $100K in student loans, a mortgage, and 2 kids in private school so walking away is not something I can just do next week.
You can't ALSO then claim that money isn't important to you. As a physician, you provide a valuable professional service that is in demand by many people. Your bargaining chip is not the revenue you've brought in through the program. Your bargaining chip is that you can be better paid and better treated elsewhere. And it sounds like under the circumstances you need to go that route.
posted by deanc at 11:47 AM on June 11, 2016
That said, when you say,
Unfortunately, I still have $100K in student loans, a mortgage, and 2 kids in private school so walking away is not something I can just do next week.
You can't ALSO then claim that money isn't important to you. As a physician, you provide a valuable professional service that is in demand by many people. Your bargaining chip is not the revenue you've brought in through the program. Your bargaining chip is that you can be better paid and better treated elsewhere. And it sounds like under the circumstances you need to go that route.
posted by deanc at 11:47 AM on June 11, 2016
I wonder if there is any hope that, since you are the sole person doing this, the grant might "follow" you if you left. Read over the grant language. I bet your patients would follow you. No one is else will take care of them.
So, spend a little time outlining what it would take to start your own practice or organization. Then explain to your employer that while you think you can probably take your hep C patients with you and the organization would lose this grant, you don't really want to work longer hours, which is generally required by founding a new thing. You just want x, y and z from them in writing. If you can't get that, you are gone because the current arrangement is killing you.
When you write up the outline, look for examples of successful companies that have enforced sane hours and humane working conditions. For example, Chik-fil-a does not open on Sundays and, historically at least, hired a lot of college students .
It is not a given that an organization must cave to market pressure. Organizations that pay at the higher end for their field see lower employee turnover which saves the company money in turnover costs and pays dividends in other ways that are harder to quantify. But having the same employees for many years means there is a richness of local knowledge that has real value.
Anyway, as others have said, be genuinely prepared to walk. Negotiations will go better if you are extremely clear about what you need from them in order to stay long term and are totally prepared to walk away if you cannot get certain essential things out of the deal.
The best way to be psychologically prepared to walk is to have other options lined up. Confidence is best thought of in the statistical sense, not as some psychological trick of psyching yourself out. If you have one or more plans you know are viable, then the worst case scenario is you go with plan b or c. That makes it vastly easier to ask for exactly what you want and not some watered down, beggarly version of what you think might fly.
Make a wish list and ask for more than you absolutely need. This gives them room to turn down some things without killing the deal. Human nature being what it is, they will be happier with the deal if you ask for a, b and c and they agree to a and b only than if you ask for a and b only and get both. Same deal, but they will feel more in control, like they actually negotiated, etc.
The hardest deals to make are the ones where there is a very thin range in which both sides genuinely benefit. In such cases, both sides typically feel the other side is "being an asshole." I think $500k likely gives you wiggle room to be a little sloppy and uncouth and still make a deal that benefits both sides. So, feel okay about it going in. Do your best to view this as a win/win scenario: "Good news guys! My efforts brought in so much money that you have the opportunity to convince me to stay. I would really rather stay, but I need less crazy hours, better money, and blah."
Pick up a copy of "Getting to yes." It is research based and a quick read. It has useful, basic info about negotiating.
If they blow you off -- and they may, just because this is an unusual situation and organizations often cannot cope with something that is too outside the norm -- seriously consider starting your own thing, taking your patients with you and applying to the grant yourself, assuming there are no legal barriers to doing so. Even if you cannot apply for this particular grant, document the fact that your work led to this. That is something you can use as proof that you can get things done, have expertise in niche thing, etc. Even if it doesn't get you what you want from this employer, it can open other doors for you.
Best of luck.
posted by Michele in California at 11:50 AM on June 11, 2016
So, spend a little time outlining what it would take to start your own practice or organization. Then explain to your employer that while you think you can probably take your hep C patients with you and the organization would lose this grant, you don't really want to work longer hours, which is generally required by founding a new thing. You just want x, y and z from them in writing. If you can't get that, you are gone because the current arrangement is killing you.
When you write up the outline, look for examples of successful companies that have enforced sane hours and humane working conditions. For example, Chik-fil-a does not open on Sundays and, historically at least, hired a lot of college students .
It is not a given that an organization must cave to market pressure. Organizations that pay at the higher end for their field see lower employee turnover which saves the company money in turnover costs and pays dividends in other ways that are harder to quantify. But having the same employees for many years means there is a richness of local knowledge that has real value.
Anyway, as others have said, be genuinely prepared to walk. Negotiations will go better if you are extremely clear about what you need from them in order to stay long term and are totally prepared to walk away if you cannot get certain essential things out of the deal.
The best way to be psychologically prepared to walk is to have other options lined up. Confidence is best thought of in the statistical sense, not as some psychological trick of psyching yourself out. If you have one or more plans you know are viable, then the worst case scenario is you go with plan b or c. That makes it vastly easier to ask for exactly what you want and not some watered down, beggarly version of what you think might fly.
Make a wish list and ask for more than you absolutely need. This gives them room to turn down some things without killing the deal. Human nature being what it is, they will be happier with the deal if you ask for a, b and c and they agree to a and b only than if you ask for a and b only and get both. Same deal, but they will feel more in control, like they actually negotiated, etc.
The hardest deals to make are the ones where there is a very thin range in which both sides genuinely benefit. In such cases, both sides typically feel the other side is "being an asshole." I think $500k likely gives you wiggle room to be a little sloppy and uncouth and still make a deal that benefits both sides. So, feel okay about it going in. Do your best to view this as a win/win scenario: "Good news guys! My efforts brought in so much money that you have the opportunity to convince me to stay. I would really rather stay, but I need less crazy hours, better money, and blah."
Pick up a copy of "Getting to yes." It is research based and a quick read. It has useful, basic info about negotiating.
If they blow you off -- and they may, just because this is an unusual situation and organizations often cannot cope with something that is too outside the norm -- seriously consider starting your own thing, taking your patients with you and applying to the grant yourself, assuming there are no legal barriers to doing so. Even if you cannot apply for this particular grant, document the fact that your work led to this. That is something you can use as proof that you can get things done, have expertise in niche thing, etc. Even if it doesn't get you what you want from this employer, it can open other doors for you.
Best of luck.
posted by Michele in California at 11:50 AM on June 11, 2016
Response by poster: You guys are great. To be clear, I am serious about walking away, but the truth is, at this point, I've worked in every care setting that exists in the US, and walking away likely means walking away from clinical medicine. Which obviously gives me a great deal of anxiety going into negotiations. I don't see myself starting a business (i.e. I'm terrible at money things) or going into Pharma or God forbid working for an insurance company. My wife and I crunched the numbers and we are prepared to downsize our lives and I'll be a stay at home dad with perhaps a little locum tenens work or consulting. The idea of "I'll be treated better somewhere else" is maybe true but not something I'm going to follow through on. If I bail on medicine I'll probably write and channel my bitterness into activism for health reform but this doesn't give me a ton of confidence about my "backup plan." But I'm hearing that confidence in getting what I want or else Serious Follow Through will happen is important.
posted by Slarty Bartfast at 12:32 PM on June 11, 2016
posted by Slarty Bartfast at 12:32 PM on June 11, 2016
Also, any hope of success hinges on convincing them that a) this $500k is there because of you b) you were planning to leave before you learned of it and see this newly discovered fact as an opportunity for both sides to benefit and c) if you walk, the grant will almost certainly disappear as well.
Do your best to document the fact that your efforts directly led to this money. Bring written documentation of that fact with you to the negotiation. Have a very succinct summary of "I did Thing, Thing led to $$$, I was considering leaving but I am hoping that we can work something out satisfactory to both sides."
Also, watch "Kingdom of Heaven" this weekend. Sucky movie, totally worth watching for the negotiation scene (you need to watch the whole movie to appreciate it).
I've worked in every care setting that exists in the US, and walking away likely means walking away from clinical medicine.
Have you worked at a Direct Primary Care clinic? It is sort of the hot new thing and some doctors are moving to that model as a cure for what ails their professional experience. It is ACA compliant when combined with the right products.
posted by Michele in California at 12:40 PM on June 11, 2016
Do your best to document the fact that your efforts directly led to this money. Bring written documentation of that fact with you to the negotiation. Have a very succinct summary of "I did Thing, Thing led to $$$, I was considering leaving but I am hoping that we can work something out satisfactory to both sides."
Also, watch "Kingdom of Heaven" this weekend. Sucky movie, totally worth watching for the negotiation scene (you need to watch the whole movie to appreciate it).
I've worked in every care setting that exists in the US, and walking away likely means walking away from clinical medicine.
Have you worked at a Direct Primary Care clinic? It is sort of the hot new thing and some doctors are moving to that model as a cure for what ails their professional experience. It is ACA compliant when combined with the right products.
posted by Michele in California at 12:40 PM on June 11, 2016
I don't work in the US, so it's possible that this won't be helpful or else it will be so obvious that you've already considered and rejected it.
I recognise the burnout you describe, and it is why a lot of my primary care colleagues emigrate to countries like Australia and Canada (which is definitely something to consider if you are really contemplating leaving medicine).
A lot of my colleagues who can't or don't want to emigrate become long-term GP locums. This is an entirely mainstream career choice in the UK - you work in a surgery for a week or so to cover annual leave or sickness, and then you leave. No responsibility for management stuff, no staying late - you see your patients and you're done. Most GPS who do this are able to work less than full time, because it pays better than permanent salaried posts. The only downside is job insecurity, as with any self-employed work. They might also do a few shifts with the OOH provider, or in A&E, or do some legal work or teaching. It isn't looked down on at all.
If you google "portfolio GP" you'll find a lot of articles on it. I don't know how common this kind of thing is in the US, but like I say it's very common over here, and seems like the obvious direction to look in if you still like seeing patients but can't cope with management any more.
posted by tinkletown at 2:58 PM on June 11, 2016 [1 favorite]
I recognise the burnout you describe, and it is why a lot of my primary care colleagues emigrate to countries like Australia and Canada (which is definitely something to consider if you are really contemplating leaving medicine).
A lot of my colleagues who can't or don't want to emigrate become long-term GP locums. This is an entirely mainstream career choice in the UK - you work in a surgery for a week or so to cover annual leave or sickness, and then you leave. No responsibility for management stuff, no staying late - you see your patients and you're done. Most GPS who do this are able to work less than full time, because it pays better than permanent salaried posts. The only downside is job insecurity, as with any self-employed work. They might also do a few shifts with the OOH provider, or in A&E, or do some legal work or teaching. It isn't looked down on at all.
If you google "portfolio GP" you'll find a lot of articles on it. I don't know how common this kind of thing is in the US, but like I say it's very common over here, and seems like the obvious direction to look in if you still like seeing patients but can't cope with management any more.
posted by tinkletown at 2:58 PM on June 11, 2016 [1 favorite]
My wife and I crunched the numbers and we are prepared to downsize our lives and I'll be a stay at home dad with perhaps a little locum tenens work or consulting.
You do have a backup plan, then. Look, you're a person who's got a lot to offer. You generated value for your company, while helping these patients. You're among the top 10 doctors in Seattle. There are options; people have talked about some of them.
(I will add that ok, maybe you're not a great businessperson [and you should probably learn something about that at some point], but maybe there's someone out there who is - who shares your values, is keen on the haggling etc. And sees an opportunity in the middle of this administrative chaos, to do some good while making some money - I mean, it can happen, you know because you did it, it's conceivable. I'm sure there are investors and colleagues who'd be interested, you can't be the only doctor who feels the way you do. Obviously, now isn't a good time to go hunting for a partner etc, but maybe, if you let yourself rest for a bit, there will be such a time.)
Consider too that right now, you're burned out. You may not be the best judge of what you'll feel like or be capable of dealing with in a year's time.
The main thing I want to say is, have some faith that you will be able to figure this out. If your wife is behind you and you're all ok with tightening your belts for a bit, you can walk away. It is probably, actually, a good idea, for your health. But you have value. Have some faith.
posted by cotton dress sock at 5:47 PM on June 11, 2016
You do have a backup plan, then. Look, you're a person who's got a lot to offer. You generated value for your company, while helping these patients. You're among the top 10 doctors in Seattle. There are options; people have talked about some of them.
(I will add that ok, maybe you're not a great businessperson [and you should probably learn something about that at some point], but maybe there's someone out there who is - who shares your values, is keen on the haggling etc. And sees an opportunity in the middle of this administrative chaos, to do some good while making some money - I mean, it can happen, you know because you did it, it's conceivable. I'm sure there are investors and colleagues who'd be interested, you can't be the only doctor who feels the way you do. Obviously, now isn't a good time to go hunting for a partner etc, but maybe, if you let yourself rest for a bit, there will be such a time.)
Consider too that right now, you're burned out. You may not be the best judge of what you'll feel like or be capable of dealing with in a year's time.
The main thing I want to say is, have some faith that you will be able to figure this out. If your wife is behind you and you're all ok with tightening your belts for a bit, you can walk away. It is probably, actually, a good idea, for your health. But you have value. Have some faith.
posted by cotton dress sock at 5:47 PM on June 11, 2016
Mod note: Final update from the OP:
I read "Getting to Yes" which is excellent. As I feared though, current leadership could not see the opportunity I was presenting them and was really focused on treating all of the cogs in their machine equally. If you are not the same as all the other cogs, then this isn't the machine for you. [This was not their words, it was more "this is what we are able to offer everyone and a non-profit like ours has limited ability to negotiate individually with employees, yadda yadda."]posted by cortex (staff) at 10:15 AM on June 12, 2017 [12 favorites]
In the end, I wasn't ready to leave clinical medicine entirely. But I *did* take a sudden, abrupt FMLA leave of absence for burnout. While my organization was freaking out and scrambling to cover my workload, I spent a lot of time with my kids, traveled, exercised, and meditated upon the kind of life I wanted for the last 20 years of my career.
I settled with the idea of spending my work days doing something personally rewarding, working with people I love and respect, protected family time, enough vacation to recharge and travel, regular exercise and meditation. Financial reward and prestige/recognition within my field are much less important to me.
Coincidentally, my spouse got a huge promotion and raise around the same time (she is also in academic medicine) which took some of the urgency I felt around the situation away. I received a lot of praise from other physicians in my support network for taking a stand and with a slight change of attitude, I felt that my best chance at getting all of the things I wanted remained with my current position.
I returned after 6 weeks and my medical director gave me the one thing he was able to offer which was a 7% raise. I was clear with them that I would no longer be able to work long hours from home at night and on weekends and whatever wasn't getting done because of that was really not my problem.
It's mostly worked so far. Yes, I'm actually working late maybe once a week, but that's a big improvement. I have vacations scheduled for the next 2 years, including a number of random mental health days. I still exercise and meditate regularly. And I am grateful for the things I have and don't have much time or energy to spare on the things that aren't worth it.
And I fully understand that maintaining my priorities may well get me fired one day, but so what.
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How much more time is on the grant? I have found that when the funding source incentivizes/requires that an organization do X in order to get $ that higher ups are more likely to comply. Sometimes the granting entity will up the award if you go to them and say, "This isn't enough." Since you know the place that got you the grant, this may be an option to explore before your org (FQHC, I'm guessing?) walks away.
It may actually be the time for YOU to walk away. What would it take for you to stay? Do you even know? Sometimes things are so far gone that you can't do much about it even if you identify and address the issues. It sounds like it may be such a toxic work environment that you can't get to where you need to be. That's your call of course, and there may still be hope.
However, I have successfully negotiated in a similar position. The formula I used was to describe the events without commentary: We got a grant for $X. In order to fulfill requirements, I increased my workload to Z. Because of that workload and my doing this, ORG now has $500,000 in reserve, in general operating funds that we would not have if it weren't for me. When we got grant, ORG told me that (what you were told). This did not happen. When Higher UP person did my job for a bit, they saw that need. The decision you made to leave the grant is short sighted. If you leave the grant, you will no longer have that income. If you spend $200,000 of it on another physician (Or whatever you need), you will keep getting it and also keep me. Because truthfully, I am overloaded and my wellbeing will not take this any longer unless you make these changes.
Etc etc.
I have to run to a conference now, but I'll check back on this later today and feel free to memail me if you'd like.
posted by Stewriffic at 4:30 AM on June 11, 2016 [6 favorites]