In 1943, Abraham Maslow’s psychology paper, “A Theory of Human Motivation,” and his “hierarchy of needs” put the basics, such as survival, at the base of a pyramid, followed by the more sophisticated human wants, such as love, esteem, and at the pinnacle, self-actualization, or the fulfillment of one’s personhood via implementations of all the talents and abilities which the lower levels engender. Human motivation, for physicians, defines its own private pyramid that you begin climbing the first day you are on the payroll of an established practice.

Doctors, especially long-established doctors, are tempted to treat their junior partners like children. It’s a variation on the “what do you want to be when you grow up?” and senior physicians are self-appointed gurus for how you should practice medicine. It’s not dictatorial or mean-spirited, however. You must remember an established practice has a good reputation for good reasons. Nevertheless, senior physicians expect their subordinates to be obedient and productive and not upset the course of the practice.

When intolerable limitations aren’t known before committing to a practice, they can brew like an ugly abscess, inflamed and painful. It’s no fun being the foreign body that initiates a practice’s innate immune system against you. This is a psychological burden that is unexpected while you’re trying balance risks vs benefits, follow a therapeutic flow sheet, or even concoct an empiric regimen. Can this burden be avoided? Just what are the warning signals?

Warning signals: look for the cracks in the pyramid before you begin

• High turnover of new physicians: Some doctors get new physicians all the time to take advantage of the subset of patients who always want to try a new doctor. Alternately, there are other heads of practices who create high turnover of partners/associates just because they cannot get along. It’s not dastardly to interview a practice’s ex-physician as long as you realize there are two sides to every story.
• Vague timeline of your progress in the practice: If there are no discussions of your progression in the practice over time, this is an open invitation for your employer to keep you stuck at one level, dangling the carrot of the next tier or promotion. No timeline means you’re a prisoner on a lower level of the pyramid.

• Generation gap: “Old school” (them) vs right out of school (you). People can be so set in their ways that not only will they persist in their usual modus operandi, but may begin to insist it become your MO, too. This is antithesis to self-actualization. Such a generation gap is not necessarily one of age. You had classmates in med school who you knew were curmudgeons even then. There were peers with whom, theoretically, you knew you’d never be able to coexist. But these aren’t just lab partners this time. A practice relationship requires harmony.

  Alternately, there are older—even much older—prospective employers with whom you’re interested based on attitude, ethics, and a sensibility of fairness. Unsure? Have many conversations. Socialize with them and their significant others. See what a Jack-and-Coke (or two) does to them. It’s like going out on a blind date. Be keen to know what turns you off, because you might miss it if you’re too keen to want to like someone. Don’t be seduced by the need for a job. Senior physicians always consider themselves mentors and will fill your social evenings with “advice.” Listen to these confidences, because they will define the person you’re considering, either being sound and well meaning or pompous and insistent – or even dangerous.

• Vacation time: It’s not unreasonable for senior partners to get more vacation time, but when their fourth or fifth vacations see you still needing another 6 months to earn your first week off, you’re the practice-minder for them: their income keeps rolling in thanks to you, yet your income doesn’t change. Know these terms before you commit.
• Income: Most newly inducted associates are on a salary. You’ll know what the going rate is before you begin negotiations—or you should. Before committing, however, know how your income will grow in the future. When does productivity kick in? If Maslow’s pyramid defines human motivation, income plays an important part in physician motivation within the practice.

Warning signals: Don’t be blind to the cracks in the pyramid after you begin

Once you’re in and problems arise, there are mental exercises you will need, so flex those neurons. Where there’s a will there’s a way, unless your employer says, “No way.” At this point, you will have to decide whether you’re better off with or without this practice. Meanwhile, keep in mind that the practice will be weighing whether it is better off with or without you. Nevertheless, some Kryptonite you need to look for:

• Pecking order: Where are you in the practice’s hierarchy of life? If you’ve entered a practice in which it seems the ancillary staff outranks you, they will expect you to do things the way they’ve always been done. This is the same as telling you how to practice, which is the worst-case scenario of being treated like a child. While you can learn much from these well-meaning individuals, if you misbehave, you can be assured you will be punished. It won’t be overtly, but with the disconcerting subtleties of curtness or questioning your judgement in front of patients—sometimes with a manipulative, “Are you sure, doctor?” and other times with a simple raising of the eyebrows and head-shaking as you make your disposition.
• Unequal call: If the hiring doctor says you owe him/her more of the lion’s share of call because of doing it without you for years, that’s not a good argument to abuse you. If you accept the call arrangement that is set in stone from the beginning, however, then you’ve been forewarned and you shouldn’t complain. Even a lopsided call responsibility is acceptable if you are willing to “pay your dues”; but as happens, abuse and expectations grow more unreasonable in a slow, insidious deterioration of your Maslow pyramid, whose pinnacle becomes higher while the base that you’re on sinks lower.
• Taking up for a patient at your expense: You’re entering a family of sorts. Your employer has worked hard to safeguard the doctor-patient relationships that define the practice. There will come a time when one of the “favorites” of the practice—meaning not your practice, will challenge you, insult you, or distrust you. This will be your most awkward challenge, because if your employer sides with the patient, it’s a professional humiliation. It’s time for a frank talk about what you’ll tolerate and the code of behavior you expect. If you’re put in your place, then your place is probably not in that practice.
• Not allowing you to look at the books. This is understandable during some unspoken “probation” period, which in most practices is a year. After that, you should expect a clear track to equality/partnership, and you have a right to know what financial windfall or debacle you’re inheriting.

There are more princes than ogres

Most of this is common sense. The problem is that you’re seduced by the authority a prospective employer wields. That being said, most of the physicians in a successful practice have earned their good reputation, and it is quite an accomplishment. While this doesn’t mean you should be abused, it is something to consider in the give-and-take as you climb your pyramid. Remember, you have no protection from becoming an ogre yourself. His or her reach across the W-2 aisle needs a handshake. You’re coming in myopic, so you need to be as open-minded as you expect your employer to be.