A discussion sparked in the EM community of Pakistan regarding the job situation and the value of EM residents when they complete their residency, pass their exams, and enter the job arena. We had two online sessions and I presented an overview to help EM physicians in their job hunt. Some of my residents have asked me to pen those ideas and guide them about the issues coming up when they go hunt for a job. The query was very valid and it had many prongs that needs to be explored. This overview will help young EM docs understand the dynamics of the job maket and also learn to know how to create a value for themselves. The issues covered here included:
- The quality of the training.
- How the resources are allocated in the emergency department.
- How the structural design of the emergency department is constructed and improved.
- What are the expectations of the employer and
- How can you be ready as a physician for the job that your employer wants to hire you for.
Before I begin commenting about these issues, let us first understand the dynamics of the change. The change starts from the right thinking and then bringing the right minded people together. After that understanding the needs and desires of the stakeholders and then working to improve the situation one bit at a time.
So in order to change the dynamics of emergency medicine and the job situation pertaining to the work of emergency physicians in Pakistan, we all need to understand the dynamics of change as well as the role of the various institutions, which are also the stakeholders, so that we would know where to start and how to bring that change.
- Institution: The institution that someone is working in, remains the most important part of the equation of change as the change has to occur in that institution and have to be brought by the people working in that institution.
- PSEM
- CPSP
- PMDC
- Other bigger Institutions not part of the Government.
If we don’t understand the task of each of the entity listed above, then we may not be able to achieve the goal of improving the situation of Emergency Medicine in Pakistan.
College of Physicians and Surgeons Pakistan.
The College works on the training post graduate doctors in different disciplines of Medicine and Allied and Surgery and Allied fields. It creates the curriculum of the training program and also approves hospitals for the training of these programs. Its focus is on the training program and the PG trainees.
Pakistan Medical and Dental Council.
PMDC is concerned about licensing doctors. It also makes sure that the conduct of the doctors are ethical, although it does it as a regulatory body and does not have any proactive stance. It can define the general standard of care, and it has shown to address some concerns arising out of the medical colleges and hospitals run by these medical colleges, both private and public. PMDC can assert more control over Medical Colleges and associated hospitals, as well as on individual doctors, but PG training is not its domain.
Pakistan Society of Emergency Medicine.
A professional body like PSEM can not legislate or create any regulation or law. Yet it can act as an agent of change. It is the most important professional body that is concerned for the well bing of EM doctors when it comes to Emergency Medicine. Recommendations coming through the society may not be binding but can have far reaching positive effects.
Let us now talk about the financial aspects of healthcare. We work to get paid, but we need to know where that money comes from. Its really important to understand the money dynamics. Hospitals both public and private run because of the money they get either through one way ot the other. These ways can be grouped as follows:
- Money provided by the Government.
- Money provided by the NGO through charity or some other ways.
- Corporations give money to hospitals for seeing their employees. Usually it is negotiated amount and can be substantially less than what private patients give to the hospitals for same treatment.
- Private patients paying themselves for their treatment.
- Social health Insurance, like sehat sahulat card.
When doctors work in different hospitals, their financial arrangements for how they get paid vary with different organizations. Some of these include:
- Defined money based on the pay scale. Mostly Government hospitals, or the junior doctors.
- Pay for the service and with incentives. You make more money by seeing more patients. This arrangement is usually in private hospitals or the Government hospitals with provision of private practice.
- Any combination of the above.
After the hospital gets paid or collects money, how will the doctors get paid. As a person trying to negotiate the salary, you should know that how much will be the salary. And also that if there are incentives to make more money over and above the salary. These revenue streams can be bundled into three groups:
- Base salary. When negotiating your salary you should know how much is the base salary, and what is expected of you in terms of work as well as hours working per week. Most Hospital want a 48 hours work in 6 days of the week. Some hospital at very junior level ask for 12 hours shift work and an average of 40 hours per week of working.
- Shift based extra income. Once the base salary is discussed then there may be some extra money for shift work. This shift work is mostly clinical. This work is paid more for social hours or at night time and for the holidays. You should ask your prospective employer the amount of money that will be given for those extra shifts.
- Incentive based money. Some of the employers give incentives for seeing more patients or doing a better job uh and in terms of bonuses at the year end. So you should ask your employer if there is any incentive based money that is offered for the position that you are opting.
At the same time when you talk about the money you always need to talk about the kind of work that is expected of you for the position that you have been offered. This includes:
- working hours and per week hours expected of you for the salary that you are getting.
- You should ask how many mornings that you will be expected to come and what is the time that clinical work starts and work schedule. Similarly the number of evening shifts and if there is any night duty that you have to perform.
- It is important to understand the expectations of the employer so that there would be no disappointments on part of either party.
You should then ask for the team composition of the Emergency Department, and the supervision or back up, if any. You should also know the ratio of doctors to patient, which means daily census of the emergency department and how many doctors are there, including yourself, to take care of their needs. You should ask, how many nurses and how many other supporting staff are present in each shift, so that you would know how you’re going to provide the care to the patients coming to the emergency department.
This will also be the time to talk about the clinical support and infrastructure of the emergency department, whether this is a fully equipped emergency department including radiology and lab availability. Whether the lab and radiology is available all the time or for limited hours. What is the turn around time for the reports. Then ask about specialty back up and if any specialty is not available, what are the arrangements and referral that you have to follow.
Towards the end inquire about the career progression and growth. Any academic prospects and any support for CME and conferences. Whether medical students and PG trainees will be rotating in the department, and what is expected from you in terms of teaching and supervision.
Lastly, talk about the contract. Is it a permanent job or on a contract basis? How long is the probation period? And how long is the notice period (both for resignation and termination)? What are the terms for the renewal, as well as the terms for the promotion? Whether they will report and submit your taxes, or is it your own responsibility? How the organization prevents violence against staff. And in case of any legal issue due to patient care, whether the hospital will protect you legally or not.
The first job after your FCPS is always exciting and challenging. Make sure that you know what questions to ask. This way, the decision making will be informed and will not lead to any regrets. Rest is always in Allah’s hand to make it right for you.