While in residency, if you have an idea of what city or area you might like to work in, use your time on consult services to take note of the practices in that area that are sending consults. Letterheads may list the pathologists in the practice, as well as contact information. Talk to peers and faculty who may be from that area to find out about the practice climate there. Once you have some names, it’s not unreasonable to start calling these practices. Find out if they anticipate hiring in the next few years, if they know what type of subspecialty training or CP expertise they might be looking for, and if you can send them a CV. Try to find out which hospitals might fall under the same group or corporate umbrella.

If you don’t have a geographic preference, you may instead prefer a certain type of practice. If you are looking at subspecialty practice, track down previous graduates from your fellowship to try to narrow down what features you are looking for in a job and what part of the country has the practice climate you are looking for. Keep watching the jobs boards at Pathology Outlines (pathologyoutline​s.​com), journals, and professional societies to see how often your desired job description comes up and where.

Once you’ve decided what you want, you may wonder who is going to want you. New graduates bring cutting-edge training to the practice, as well as enthusiasm and a willingness to learn new skills (usually!), so private practices are willing to invest time in bringing a newbie up to speed in order to get these benefits. New graduates may also be cheaper to employ than seasoned professionals, so a practice may be happy to replace a retiring senior pathologist with a brand new one.

In addition, practices are looking for:

More specifically, community hospitals often need someone who is AP/CP certified to take over some medical directorship duties. A subspecialty fellowship may not be necessary; this is where you need to do your research in advance to find out what the needs are in your target area. If all of the local prostate biopsies go to GU-R-Us, having a GU fellowship would not bring much value to a hospital in that area (but may be just what GU-R-Us us looking for). General surgical pathology fellowships are always useful, though, especially if they give you sign-out experience that will enable you to hit the ground running.

There are some definitions and concepts you should know about private practice. One is that there are two basic ways a pathology group can be organized: as employees of a larger organization (hospital or lab) or as an independent contractor. Independent contractors are privately owned practices (or, rarely, individual pathologists) that may work within a hospital setting but are paid for their services by the hospital (as opposed to being employees of the hospital). What’s the difference?

Employee : The hospital/lab pays the pathologist a salary and is responsible for benefits, withholding taxes, hiring and firing, job expectations, malpractice insurance coverage, etc. The hospital bills and collects for the professional services of the pathologist .

Pros:

Cons:

Independent contractor : The hospital pays for the services of a privately managed group or individual. The group or individual bills for their own professional services but also must cover benefits, salary, taxes, insurance, etc. A group may be just a cohort of physicians, or they may have some overhead expenses or capital investments (office space, equipment, computer systems) and non-MD staff (transcription, pathology assistants [PAs], techs, couriers). In addition, some independent contractors may outsource their billing right back to the hospital (called reassigning) and negotiate a percentage, per diem, per discharge, or per member (capitation) reimbursement from the hospital.

Pros:

Cons:

Billing is a huge and complex topic that varies by state (and by year, as regulations change). There are some generalities about Medicare payments that are important to understand. Hospital services provided by pathologists that are paid for under Medicare Part A include all non-billable services (teaching, conferences, medical directorship, autopsies, committee work, etc.). Only a hospital can be paid for Part A services. Part A compensation for non-Medicare patients is different with every hospital—it may be handled just like Medicare or not. The hospital may pay an independent group a fixed annual fee that covers Medicare Part A services, or it may be linked to patient or test volume, productivity, or lab revenues.

Part B is billable work—whatever has a CPT code—and can be AP or CP. Part B includes a pro fee (the MD or professional fee) plus a technical fee (the work done by the lab). Pro fee + tech component = global fee. Part B can be billed to the patient/insurer by the pathologist or by the hospital on behalf of the pathologist . In addition, outpatient charges, which are usually billed per service, are handled differently from inpatient charges. Inpatient services may be reimbursed under the DRG payment (diagnosis-related group), which covers nearly all lab testing and the technical component of AP for a flat fee determined by diagnosis, or they may be covered on the basis of population health payment models, which give hospitals a fixed overall budget for services.

The reason any of this matters to you is that, especially if you are looking at an independent contractor arrangement, the way your services are paid for is your bottom line. You need to understand the basics of payment well enough to be able to ask salient questions when evaluating a job. One possible arrangement is that a practice is contracted by a hospital, which pays the practice a flat annual fee to cover Part A work (for which the hospital is reimbursed from Medicare ), and the practice runs its own histology lab so it can bill global fees (professional and technical). In this scenario the risk of fluctuating volumes or reimbursement rates rests entirely on the practice, but if the practice has a really good year, they keep all the revenue. Another arrangement may be a practice that uses the hospital’s histology lab and lets the hospital bill for technical services while the practice bills only the professional component. A third possibility is a practice that is not affiliated with a hospital at all and only does outpatient work, for which they bill global fees directly. As a new graduate, you will not be expected to be fluent in these things, but once you get to the stage of a job interview, you must get the practice to explain it to you in sufficient detail that you have some idea of the potential strengths and weaknesses of the arrangement.

All of these details must be spelled out in a contract. Don’t seriously consider any job offer on a verbal or back-of-the-napkin basis. A contract (which may be different for employees and for partners) should spell out everything: compensation, benefits, opportunity for partnership, expectations, vacation and leave policy, conditions of termination or departure, malpractice insurance (including tail coverage, which is the insurance that covers you after you leave a group), retirement plans, and so on. The more details, the better. Have a lawyer familiar with physician contracts review it for you for red flags or omissions. If you are geographically restricted, you may end up in a take-it-or-leave-it situation, but even then, it’s still important to know what you are signing up for. No practice or contract is perfect, but you must be able to make an educated choice based on known quantities, and that includes knowing how you might get out of a practice if it turns out to be a bad fit. Watch for noncompete clauses, which can bar you from taking another job within a certain radius of your old hospital.