901 N. Washington Avenue
Lansing, Michigan 48906-5137
Telephone: (517) 485-5484
FAX: (517) 485-0801
E-Mail: saem@saem.org
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901 N. Washington Avenue Lansing, Michigan 48906-5137 Telephone: (517) 485-5484 FAX: (517) 485-0801 E-Mail: saem@saem.org |
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AUTHORS
| Rita K. Cydulka, MD
Assistant Professor Case Western Reserve University |
Charles L. Emerman, MD
Associate Professor Case Western Reserve University |
Jeffrey Jones, MD
Assistant Professor Michigan State University College of Human Medicine |
| Leonard Justice
Executive Director Maricopa Emergency Physicians |
Joseph LaMantia, MD
Assistant Professor Albert Einstein College |
John B. McCabe, MD
Professor and Chair State University of New York, Syracuse |
| C. Keith Stone, MD
Assistant Professor East Carolina University School of Medicineof Medicine |
Harold A. Thomas, Jr, MD
Assistant Professor Bowman Gray School of Medicine |
Alexander Trott, MD
Professor University of Cincinnati |
| Chapter | ||
|---|---|---|
| 1 | Basic Principles of Negotiation | Harold A. Thomas, Jr, MD |
| 2 | Understanding Promotion and Tenure | Alexander Trott, MD |
| 3 | Negotiating an Emergency Medicine Faculty Position | C. Keith Stone, MD |
| Rita K. Cydulka, MD | ||
| 4 | Negotiating a Residency Director Position | Joseph LaMantia, MD |
| 5 | Negotiating a Research Director Position | Jeffrey S. Jones, MD |
| 6 | Negotiating a Departmental Chair Position | Charles L. Emerman, MD |
| John B. McCabe, MD | ||
| 7 | Evaluating Benefits as Part of Your Compensation | Leonard Justice |
Negotiation is a necessity, although few appreciate its importance. Everyone negotiates daily with their
families, coworkers, even their patients. Many people look with disdain on the process, however, the
development of some basic skills will increase effectiveness in all areas of life, particularly when
considering a major career move.
THE THREE STAGES OF NEGOTIATION
All negotiation goes through three distinct stages:
Stage I - Clarifying the Objectives: each party determines what the other wants.
Stage I: Many incorrectly believe that negotiations start at Stage III and hurry through the first two stages.
This assumes that both sides already know what the other wants. Avoid this error by explicitly identifying
the needs of the other side, for example: "I want x number of dollars each year." The best agreements will
be reached by understanding the reasons behind this position. For instance, one may wish for a certain salary
but the reason is to meet college tuition costs, and this need could be met by a free tuition program. As
another example, a program may insist on a July start date for new faculty but really only need extra
weekend coverage during the busy summer months.
Stage II: The exchange of information is the most important stage and should be the most time consuming
since it sets the tone for all further discussion. The most important way to succeed at negotiation is to obtain
as much KNOWLEDGE as possible about any prospective faculty position the institution and the individuals
involved in the negotiations. Table 1 lists some important but often overlooked factors. Resources include
discussions with the Dean, hospital administrators, EM faculty, departmental secretaries, house officers,
nurses, faculty in other specialties at the institution and emergency physicians from other programs. Return
to these sources as your knowledge base develops. Most people will be very willing to help in Stage II when
they do not realize they are negotiating. In addition, both parties learn about and begin to trust each other.
The investment of time in this stage of negotiations sets up an incentive to work toward a successful
outcome.
There are important accomplishments during this stage. The employer is given time to adjust to proposals.
A request that may be rejected during formal negotiations may become more acceptable if it is brought up
earlier as a preliminary idea. If the prospective employer develops ownership early in the process, he or she
may be more likely to support proposals during Stage III formal negotiations. There is also time to develop
self-knowledge. An individual will be a more effective negotiator when there is an understanding of one's
real needs. Conventional negotiating strategy emphasizes the importance of establishing a minimum
settlement point, such as the lowest acceptable salary. This requires a great deal of honest self-evaluation
to separate legitimate financial requirements from ego requirements. A predetermined minimum set point
made without psychological pressure avoids over-compromising from the natural desire to reach an
agreement. The disadvantage of setting a minimum set point is inflexibility when given new information or
novel proposals, and it is very difficult to develop a minimum for each area under negotiation. Great insight
is required to know how strenuously to insist on various needs. Requests for resources such as additional
residents, more lab space or an another administrative assistant are more likely to be granted before starting
a job, but on the other hand, establishing rigid positions during negotiations may so antagonize others that
nothing further will be granted after employment. Again, in long term relationships, the needs of both sides
must be met.
Individuals tend to underestimate their own importance when dealing with prestigious institutions. An
important part of self- knowledge is a realistic assessment of an individual's worth to an organization. In
discussions with colleagues and mentors, each person needs to understand the unique talent and capabilities
they have and make sure the institution realizes the benefits. At this time, there are more academic positions
available than ever, and the trend is for more academic positions in the future.
Stage III: Formal negotiations begin during Stage III. Remember that negotiations are for a total package,
not simply salary and clinical hours. Table 2 lists some concerns which should be addressed, including
malpractice tail coverage, investment in retirement funds, disability programs, and medical insurance. Some
benefits, such as the amount of malpractice insurance, may appear fixed, but in reality almost any item can
be negotiated if it is critical to concluding an agreement. Remember that agreements that are sufficient now
may need to be adjusted in the years to come. These include salary increases, projected academic
advancement, and future responsibilities. It is important to understand the expectations the employer has as
part of the agreement. In this final stage most agreements are not concluded until just before (or even after)
a deadline. Negotiations may drag on for months without apparent resolution, but as the deadline (artificial
though it may be) draws near, creative agreements are reached and important concessions are often granted
at the last minute.
WIN/WIN NEGOTIATING
While almost everyone agrees about the importance of win/win negotiating, many people still practice, at
least in part, a win-lose strategy. With a win/win approach both sides work together to find the best solution
for all concerned, perhaps even a better one than either alone could have envisioned. The emphasis is on
cooperation, maximal shared information and joint problem solving. Win/lose negotiating, or pure
bargaining, where the more powerful side extracts concessions from the less powerful, is unlikely to lead
to a successful long-term relationship. People may not forget their initial defeat or support you or your future
goals. It is important to recognize when a win/lose strategy is being used, particularly if one pursues a
win/win style and is very self revealing. There are six elements of a win/lose strategy:
Win/win negotiating demands that one try to see the other's point of view. It does not require excessive
compromise, at the expense of one's interests. Nobody wins if bad agreements lead to unhappy faculty. On
some issues, the relationship may be more important than forcing a showdown, while on others a firm stance
is warranted. This is decided based on the importance of the issue and the alternative to reaching an
agreement.
OTHER PRINCIPLES OF NEGOTIATION
A few other principles should be kept in mind during all stages of negotiation.
Focus on interests. not positions. Allow others to save face. "Face" is seldom attributed enough importance
in western culture. Many discussions break down when one party is backed into a corner without an
honorable way to adjust positions. For example, it is difficult to reopen talks after one party has given what
has been stated as an "absolute final offer." Being attuned to this can allow negotiations to proceed where
they may otherwise stall. A statement such as "I felt the same way as you until I found out that...," may give
the other person an excuse to change positions, and new information can hasten your negotiations.
Generate multiple options. Throughout the process, generate as many options for each issue as possible,
without considering their feasibility at first. Selecting one option at this early stage will prevent the
consideration of other possibilities. As options are identified they should trigger still more options. The best
solution may be some combination of ideas developed for different issues (for example sharing a research
Ph.D. with another department and using the money to fund another resident position).
Base Decisions on OBJECTIVE CRITERIA. An important question to ask those with whom you negotiate
is "what did you base your proposal on?" Outside objective criteria, where available, can serve as the basis
for a fair proposal. A new chairman's salary should be in line with what other chairmen within the institution
make. A salary survey of various academic positions is available through SAEM. The salaries of many
government positions are matters of public record. These objective criteria can keep personalities from being
an issue and also use time to the best advantage. The focus should then identify the criteria, which should
be used now to modify them.
Summary
Lastly, remember that negotiating is basically a game and like all games one can develop specific skills. One
of the most important ways to develop such skills is practice. Get a spouse to take the opposite side and
practice mock negotiations or buy a new car or house, just for practice.
II. Emergency Department
III. Relationships
Background
The P & T system helps define a faculty member's career pathway in many academic medical centers.
Because the "clock starts ticking" once a candidate is hired and given a tenure track appointment, the
candidate needs to know the rules and particulars of the P & T system as they apply to the institution and
to Emergency Medicine faculty.
Academic tenure was created to protect the academic freedom of teachers and scholars. Before the era of
civil rights and modern employment laws, academic scholars (particularly those with unpopular points of
view) were subject to arbitrary harassment and dismissal. Achievement of tenure, through scholarly
accomplishment, assured progressive thought and expression so that the tenured professor was guaranteed
a lifetime appointment including salary protection. Tenure was created with book scholars and bench
scientists in mind. The traditional seven years to achieve tenure, "the up or out system," derived from those
earlier times.
Medical school officials are increasingly reluctant to award tenure, fearing that aging scholars will lose
incentive to maintain academic productivity once their salary is guaranteed. Productive academic clinicians
feel that they deserve tenure for their clinical research and contributions to student and resident education.
Because faculty with tenure are viewed as worthy of respect, pride is central to this issue. Nobody wants
to be a second-class academic citizen.
The probationary period or pretenure appointment varies among schools, although it averages about seven
years. In most schools, faculty who achieve tenure are released from periodic evaluations and contract
negotiations. In some schools, however, contracts continue to be renegotiated or "rolled over" at given
intervals. Tenure usually comes at the title level of associate or full professor. The award usually guarantees
full title for the academic life of the clinician. Typically, the medical school (or parent university) provides
a base stipend for academic activities. The department, through a practice plan, issues a separate check for
clinical services, and tenure often applies only to the academic portion and very few schools guarantee a full
clinical salary.
The specific criteria for awarding tenure and promotion vary between schools. There may be similarities in
the criteria for tenure and non-tenure tracks, varying by degree and extent, but the underlying principle is
that tenure is reserved for those productive individuals whose contributions are perceived to be of significant
and ongoing value to an institution. Funded laboratory research is considered the most important area of
endeavor by traditional medical school P & T committees, with clinical research deemed less prestigious.
Funding, usually from external sources, is not considered important until it reaches the mid or high six
figures in dollar amounts. The primary investigator of a National Institutes of Health funded project is the
most valued for promotion. Other prestigious funding agencies include the Centers for Disease Control and
large private or public foundations. while commercial or pharmaceutical company funding is not as
important to the P & T committee, these contracts provide a start for young investigators and might lead to
opportunities at the federal or foundation level. Publishing is another key activity in the P & T committee
deliberations. Refereed and non-refeered are the two types of journals that report scientific medical
information. Manuscripts submitted to refereed journals are distributed to peer reviewers who help the editor
in the decision to publish. Scientific reports of research efforts are evaluated for soundness of methodology
and conclusions as well as many other criteria. P & T committees view these publications as being very
important. Scientific reviews, case reports, articles in non-refereed journals and textbook chapters are
awarded much less importance by the committee.
The committee also considers teaching accomplishments. EM faculty spend much of their time in resident
education; however, the contribution toward medical student teaching is usually considered more important.
The committee will consider the number of students taught, total student contact hours, and student
evaluations. Some schools are trying to emphasize teaching more, but still give it less value than research.
Activities that receive even less attention are service on medical school and hospital committees, and
membership and participation on local regional and national specialty societies.
In recent years there has been considerable debate about the role of tenure for clinicians/educators, since
most of the clinician's time is devoted to patient care, at the expense of academic responsibilities. Many
university faculty are strongly influenced by the American Association of University Professors, (AAUP)
an organization led by basic scientists, and they feel that clinicians, untrained in the rigors of scientific
pursuit and research, should not receive tenured appointments.
Clinician/educators achieve tenure by extraordinary teaching or clinical achievements. They must still
demonstrate some research activity although not at the same funding level or intensity as the traditional
researcher.
Before the issue of P & T can be appropriately addressed during the negotiation process, the academic status
of the emergency medicine program must be clarified. Free standing academic programs of emergency
medicine, such as full departments or divisions of the dean's office, will often have their own P & T
guidelines, appropriate for the academic practice of emergency medicine. If the emergency medicine
academic unit is housed within another department, those departmental guidelines may not be appropriate
to the academic needs of the EM faculty. The academic chair should be asked to clarify the prospects for
promotion for EM faculty under the P & T guidelines of another specialty department.
Once the academic status of the P & T program is understood, the candidate and chair determine whether
a tenure or non-tenure position applies to the specific appointment being sought. The chair's
recommendations go through the dean for the institutional P & T committee approval, but the actual
appointment is granted by the governing board of the medical school or university. A separate but concurrent
process is initiated for appointment to the hospital staff. Medical school and hospital appointments can be
coterminous or separate depending on the institutional arrangements.
In some schools, the initial academic appointment will be to an open or general track where the faculty are
appointed at the instructor level. This initial appointment period is usually limited to three years before
assignment to a formal tenure track. In recent years, there has been increasing competition by researchers
in all fields for available research dollars and medical schools may use this open track to provide more time
for development, and forestall faculty from prematurely sitting for tenure. In such a system, ten years can
pass before faculty must achieve tenure. If there is no general track, then a specific assignment will be made
to either the tenure or nontenure track. The initial title granted is either at the instructor or assistant professor
level. For the applicant, the time at which one will be nominated for promotion or tenure should be defined,
rather than left entirely open-ended, or at the department chair's discretion.
Once an initial appointment is granted, there are specific administrative requirements for advancing through
the system. Most medical schools periodically notify faculty of the criteria for tenure eligibility,
reappointment, and promotion. When they are nominated for promotion or tenure, faculty must document
their clinical, teaching and scholarly activities for consideration. This documentation includes letters of
recommendation from colleagues and prominent academic emergency physicians, as well as evidence of
teaching efforts and of research and other publications. These are first studied by the departmental P & T
committee which makes a recommendation to the chairperson. The chair then forwards favorable
recommendations to the dean and the school P & T committee. All promotions are approved by the
governing board of the school or parent university. Unfavorable recommendations can usually be appealed.
If one is hired into the nontenure or clinical track, the primary responsibility is clinical and teaching with
lower requirements for research. In this track, the faculty member negotiates periodic contracts of one to
five years in duration based on continuing performance. Faculty in the non-tenured clinical tracks are
identified as clinical assistant, associate, or professors of emergency medicine. when academic programs of
emergency medicine reside in departments other than emergency medicine, appointments are made to that
specialty area. For example, an emergency physician may hold the title of "clinical associate professor of
medicine".
Once in a particular track, transfer can take place to another. There is always the possibility that personal
maturation, circumstances or career aspirations might change. Most schools provide for track transfer in
either direction. Individuals on a tenure track but with a clinically oriented career can transfer to a non-tenure track. In some schools, there is a time limit to make this decision before it becomes irrevocable.
There are no general rules governing transfers from one academic institution to another. Appointment,
tenure eligibility, and salary are entirely up to the new chair and local institutional guidelines. Tenure is not
transferable but can be granted directly by the new school. The title and award of tenure again will depend
on prior achievements, but it would be rare to regress in title and, frequently, a higher title is granted. Such
promotion and awards of tenure are sometimes used as a recruiting incentive.
In spite of presumptive guarantees, universities have a variety of methods to terminate tenured faculty.
Universities can fire individuals based on cause, such as violations of the law or ethics. Recently, precedent
has been set for firing physicians when the university could demonstrate limited or diminishing financial
resources. Non-tenured faculty are removed simply by non-renewal of the contract. Occasionally,
termination of both tenured and non-tenured faculty has been accomplished through financial settlements.
Because P & T systems are different for each medical school, the candidate should ask to see the Faculty
Handbook. This will list the specific policies, procedures, and guidelines used for that institution. Established
academic departments of emergency medicine may have guidelines specific to their P & T committee.
Finally, the Association of American Medical Colleges (AAMC), in Washington, DC, publishes a
compendium, entitled, Faculty Appointment Policies and Practices, listing all U.S. medical schools' P &
T policies.
NEGOTIATING AN EMERGENCY MEDICINE FACULTY POSITION
The expansion in the number of emergency medicine training positions has created an increased need for
residency trained faculty and these needs continue to grow as the specialty matures. This chapter discusses
the important factors in evaluating a faculty position.
The combined attending and resident staffing must be adequate to cover the patient population, volume, and
acuity. Typical community staffing patterns have presumed that a physician can see 2-3 patients per hour
or that one full-time faculty equivalent and 3 residents are required for every 5000 patients. These
assumptions vary depending on volume, acuity, the physical layout of the department, number of treatment
areas, the presence of a fast track, and the number and quality of the housestaff. There must also be time
available for resident supervision. Another measure of the adequacy of staffing is the percent of patients who
leave without being seen, which should average less than 3 %. Observation of a busy shift will show whether
the clinical time is devoted mostly to primary patient care, administrative problems, or housestaff teaching
and supervision. The pace of the department should be assessed to determine if it is consistent with teaching
and academic discussion about patient care. If the attending physicians are seeing a high percentage of
patients as the primary provider, then that supervision will suffer. Current faculty can also provide an
impression of the pace of the department and the staffing required for safe practice. The residents can
provide a view of availability of the attending staff.
There must be a willingness on the part of consultants, both residents and attending, to provide timely care
to patients in the emergency department. The working relationship between the EM staff and the consultant
services must provide for good resident education along with good patient care. Determine which consultants
are in-house at night and how long it takes for them to respond to the ED.
Medical control of EMS and air medical services can also occupy an attending's time, particularly if triage
of air medical flight requests if required. There should be policies for accepting these patients and
responsibilities for on-line control of ground and air ambulances should be clearly defined. Inter-hospital
transfers may detract from patient care and resident supervision. Determine who accepts transfers, whether
all transfers have to go through the ED, and the volume and appropriateness of these transfers.
Evaluate the availability of ancillary services, the nurse staffing, the timeliness of laboratory and radiologic
services, and the physical layout of the emergency department. Information from departments of similar
volume and acuity can provide a basis for comparison.
Determine if there is recognition or compensation for performing extra duties, such as extra shifts and
administrative tasks. The amount of non-clinical time should be sufficient for conferences, research, and
other academic or administrative interests. The director may require demonstrable accomplishments such
as publishable manuscripts or grants as a condition for continued protected time or there may be a
requirement to buy back protected time with clinical earnings or grant money.
Most chairs have a particular management style. Decisions made by departmental committees chaired by
senior staff must be fairly considered for implementation and not subject to automatic veto by the director.
An autocratic leader may be incompatible with senior faculty who prefer consensus decision making. On the
other hand, faculty who wish to avoid administrative matters prefer a director who is able to make the
difficult decisions. Current faculty can provide a view on whether the director involves them in formulating
departmental policies.
The chair is in a position to advance careers by facilitating appointment to national committees, collaborating
on research projects, and recommending faculty to book editors. Other faculty can provide insight into the
chairperson's willingness to develop new faculty along those lines and this can be assessed by reviewing
faculty turnover, awards of tenure, research productivity, and faculty appointments to committees. One
should be hesitant to accept a position with an acting chairperson, since the expectations of the permanent
chairperson may be much different than those of the acting chairperson.
Administrative responsibilities for faculty include coordinating or serving as an assistant for EMS, air
medical services, medical student education, quality assurance, or disaster planning. Ideally, there will
be an opportunity to participate in a specific area of interest and if not, there should be a clear
understanding of the progression to desirable positions over time.
Most departments require participation on committees which may include departmental, hospital, or
university committees. The authority given and activity and time commitment required will vary. Some
committees will allow for interaction with faculty from other departments with the reasonable expectation
that the committee's work will have a meaningful impact. Other committee members will provide a view
on the scope of the duties and the time required for service on the committee. Junior faculty should not agree
to serve on more than one or two of these committees to prevent distraction from higher priorities.
If service on committees is required, the ability of the chair to recommend faculty for placement on desirable
committees should be determined. Service on committees that have high visibility and authority such as the
Quality Assurance, Curriculum, Promotions and Tenure, or Human Investigation Committees may be
beneficial in promoting one's career and enhancing the status of emergency medicine. These will also
provide interaction with leaders in the institution. Other committees such as the CME Committee, Pharmacy
and Therapeutics Committee, Infection Control Committee, and Admissions Committee may yield less
benefit. The status of various committees is institution specific however, and thus careful investigation will
be required before committing to a specific assignment.
Much of the teaching responsibilities will revolve around residents, including bedside teaching, providing
supervision and delivering lectures. There may be additional requirements for giving lectures to and
supervising non-EM residents and medical students. The department may sponsor education for EMS
personnel and nursing staff, or require participation in short courses such as Advanced Cardiac Life Support
or local Continuing Medical Education courses.
The research and publication expectations should be clearly defined. It may be important to identify mentors
to help develop research skills and there may be time and funding for graduate level courses on research
design or biostatistics. Faculty with an interest in bench (laboratory) research will need to assess the
availability of lab space and equipment. Clinical investigators will be concerned with the patient population
and availability of research assistants. Cooperation from ED staff is essential for conducting clinical studies.
Financial support should include a departmental or institutional research fund. There may be specified funds
for young investigators. When grant support is a condition for the award of tenure there must be adequate
staff in the institution to assist with the identification and preparation of grants, along with computer and
adequate secretarial support for manuscript preparation. Evaluate whether other departments will help with
studies and statistical, computer, and secretarial support.
There may be a formal faculty development program in place in the department. Other tangible areas of
support include office space and adequate secretarial support. There should be an adequate number of
computers for faculty use and provisions for slide and graphics preparation. There may be an opportunity
to negotiate for the pursuance of advanced degree courses, fellowships, or extended extramural courses in
a particular area of interest. These include coursework and degrees in statistics, public health, or business
administration programs. Free tuition programs or funding for sabbaticals may be faculty prerequisites.
With greater academic achievement and rank should come an increasing level of responsibility within the
department, the hospital and the university. Find out whether this position provides ample growth
opportunity. The best evidence of a supportive environment is the presence of nationally prominent faculty
in addition to the chair.
The local and national status of the chair can have a significant impact on the advancement of the faculty.
A nationally prominent chair will have the opportunity to involve the faculty in state or national ACEP and
SAEM committees, research projects, publications, books and task forces. A chair whose time is spent
entirely on institutional politics may be less able, or willing, to help the faculty in developing their own
careers. On the other hand a chair may be so involved in outside activities that the administration of the
department suffers. The balance between these extremes should be appraised during interviews. Current
faculty may provide some insight into these matters.
Additional academic responsibilities include supervision of residents, medical students, nurse practitioners,
paramedics, and ancillary personnel. A faculty member may be responsible for as many as four conferences
each month. Clinical faculty participation may be less. There may be expectations for attendance at all
conferences and journal clubs. The department may require faculty to participate in courses such as ACLS,
BCLS, BTLS, and ATLS. There may be additional projects such as EMS outreach or programs for
community physicians. while all of these endeavors are appropriate for academic faculty, a realistic appraisal
of the job requirements, expectations and rewards should occur during the interview process.
Outside professional work as teaching, consultation, writing, or legal consulting may be allowed by the
department, although the income may be subject to departmental taxes. Learn if the hospital or university
keeps patent rights on intellectual property.
There are many sources of information on academic job openings. Other faculty can be an invaluable source
of information through their contacts. Emergency medicine journals, AAMC newsletter and the SAEM
monthly newsletter contain advertisements detailing available academic jobs. Direct mailings to residency
programs also provide notice of openings. Contacts can be easily found at the ACEP and SAEM annual
meetings. In addition, the Emergency Medicine Residents Association provides a comprehensive job catalog
each year that contains multiple listings of available academic jobs. Lastly, physician recruitment firms
occasionally offer academic positions. Be aware that the recruiter makes a commission only when a contract
is signed so there may be considerable pressure to join a certain group.
Certain academic positions are not advertised in any manner and it may be productive to contact and send
a curriculum vitae to those institutions which meet your needs. A follow-up phone call can be made if there
is not a response within two weeks. Once a contact is made, phone contact is essential in order to get basic
information about the position and this will also allow a first impression of the chair. The checklist in Table
1 may be helpful in this regard.
The information exchanged during this call will be the basis to accept or reject an interview. If the position
appears to meet professional and financial goals, an interview should be arranged. Beware of any institution
that will not underwrite the expenses for interviewing faculty candidates as this may indicate a general lack
of support for emergency medicine.
The interview process should occupy at least a full day. Many interviews begin the evening before with
dinner with the chairperson. This allows a one on one discussion in a more relaxed atmosphere. The day
should consist of interviews with faculty members, and at least one hospital and one nursing administrator.
A meeting with residents is desirable but may not be possible on the first visit. There should be a tour of the
ED, offices, library, and research facilities if applicable.
A second interview allows for a valuable re-look at the program as well as the opportunity to meet with other
key individuals at the institution. If the position is within a medical school, an interview with the dean or
his representative could be helpful, particularly if a senior position is at stake. A meeting with another
department chairperson may be helpful as well. Time should be allotted for exploration of the area to include
housing, schools and recreational facilities. Second interviews should be sought only at those institutions
under serious consideration.
Once a decision to accept a position is made, a formal letter of acceptance should be addressed to the chair.
Courtesy letters should be sent immediately to other institutions informing them of the decision. A contract
outlining the employment agreement should be forthcoming. Medical school bureaucracies may slow the
process of contract formation in which case a letter of intent of employment should be requested.
The opportunities for recent residency graduates to gain employment in academic emergency medicine are
excellent. By carefully evaluating career goals and integrating them into the job search process, the first
teaching position will become the foundation on which to build a successful academic emergency medicine
career.
The position of a senior faculty member in an Emergency Department can be very exciting. It can offer
multiple opportunities for further clinical, academic, and administrative growth. Ensure that this position
offers the opportunity to advance individual goals and negotiate for the time and resources to foster
professional growth.
Clinical Responsibility
Authority
Responsibilities
Benefits
Negotiating a Residency Director Position
Institutions have a director of medical education or a chair of a graduate medical education committee.
Determine the role of this person in setting institutional policies and their influence over individual
programs. Past minutes of the GME committee may reveal ongoing problems that have not been
addressed.
Ask how the institution promotes itself to medical students. Review the institution's success in recruiting
residents into its programs. Since the training of your residents is partly dependent on the quality of
other programs, the status of other programs should be reviewed. The philosophy of the medical center
regarding resident education is also apparent in its academic affiliation, and those agreements should be
reviewed to insure that they meet EM RRC requirements. Determine whether emergency medicine has
access to academic resources equivalent to other departments. Access and influence is most easily
achieved if emergency medicine is a free standing department, although some programs operate well as a
section or division of another department. When the program is a division of another department, there
must be active support of EM and the goals of the program must be consistent with the plans of the
parent department.
Determine how EM specifically fits into the institution's overall philosophy, particularly insuring that the
program is not supported solely as a means of staffing the ED. An understanding of the way in which the
program contributes to the institution's strategic objectives will aid in structuring requests for increased
resources23. The degree to which other departments support the EM program and its educational
objectives must be determined. For example, the agreement negotiated with surgery must provide senior
EM residents with the opportunity to lead trauma resuscitations and allow junior residents to perform
procedures. Other support includes the authority of emergency physicians to admit patients, perform
procedures, and request consultants.
The ED must provide a milieu in which the residents can function without undue stress and conflict. A
review of this will identify areas which should be negotiated prior to accepting a position. Previous RRC
site survey reports will identify areas of deficiencies. Review clinical affiliations with other institutions
and determine the rationale for those agreements. These may point out areas of educational weaknesses
or funding difficulties. Review the recent performance of the program in the match. The department's
commitment to the residency can in part be determined by whether the chair and faculty all participate in
the interview process.
There must be enough EM residents to constitute a "critical mass " in the ED. This will vary by the
number of training sites, the number of outside rotations and the patient census and acuity. If the
numbers appear inadequate then additional funding should be negotiated for program expansion. The
residency director may want to a have a specific budget, along with a discretionary fund to cover items
such as resident travel, research or other educational expenses (Table 2).
There must be at least one dedicated residency secretary supervised by the residency director. The
director will want to insure that there is adequate storage for program files, educational space for
conferences and a library. The residency director may also want to have a budget for items such as
resident computers, software, slide making equipment, and photocopying.
Special emphasis has been placed throughout this chapter on the evaluation of the educational program.
The residency also depends upon the scope and quality of its research efforts3'4'5. There must be a core
group of researchers in the department. Assess the effectiveness of the research director, the track record
for publications and grants and any plans for research development. If these are inadequate, the chair
should be questioned about plans for enhancing the research effort, particularly as it relates to resident
education in research.
Determine the particular strengths and weaknesses of the emergency medicine chairman. The key factor
to determine is the director's commitment to faculty development. This will be evident in the time
allotted for non-clinical duties, in the funds provided for meetings, research, and other appropriate
academic expenses, and the extent to which other faculty members have been successful on a national
level. Meet with key faculty to discover their interests and goals, along with current residents to
determine their needs. Recent residency graduates may be willing to shed some light on the real
workings of the residency program. Finally, unless this is a new program, an outgoing residency director
will exist. This person should have considerable insight and should be contacted.
Status of Emergency Medicine
Resident salaries
Negotiating a Research Director Position
Interviews will require the exploration of a number of areas. Few programs will be able to fulfill all
of one's wishes and the importance of each requirement will need to be considered. Negotiation and
information about the following items will provide a view of the expectations and benefits of a position
under consideration.
The priority assigned to research by the organization is reflected by the money, space, and faculty time
provided. If the leadership is committed to furthering emergency medicine research, it is more likely that
research will be nurtured and additional support will be provided at critical times. Previous research
directors at the institution may provide information about areas where there have been conflicts or ways
in which the position and its responsibilities have changed. The previous research director may be able to
give you insight into the department's true commitment to research. The amount of money, space, and
protected time for faculty provide additional clues to this commitment.
Current faculty may provide information about the IRE process to determine if there are long delays in
obtaining approval. The IRE should have input from emergency medicine faculty. There may be
limitations placed by the IRE on the types of clinical studies which can be performed in the ED such as
studies which require waiver of informed consent. There may be limitations on industry sponsored
research. Each institution will have unique policies regarding approval for grant requests, managing
grant funds, indirect costs, and control of grant money.
If there is not a tenure tract, determine the chairman's expectation for faculty research. Since faculty
interest in research will vary, the chair must be willing to use his/her authority to ensure that patients are
enrolled into protocols. There are advantages and disadvantages to joining a group where other faculty
share your specific research interests. Where there are common interests, there may be an opportunity to
share resources or laboratories. On the other hand, conflicts may arise over the priorities in which
clinical protocols will be studied. The research director may wish to have a role in guiding the direction
that departmental research will follow, in order to efficiently utilize resources. It may be appropriate for
the research director to chair a departmental research committee that reviews all projects in order to
ensure that they will not conflict with each other and to set goals for the group.
It is useful to assess the relationships with other academic departments to determine if other groups will
be willing to collaborate on important projects. The cooperation of the nursing staff is essential in
clinical projects for subject enrollment. The views of the head nurse will determine the role of nursing in
the conduct of clinical projects.
Responsibility for the success of both clinical and basic research ultimately rests with departmental
chairs. Chairs must use their position in the hospital and university to obtain the resources of protected
time, salary, facilities, and support personnel required by investigators. The faculty development
program should include research topics and there should be a long range plan for research development.
The research director should have the opportunity to modify these plans and expect a commitment of
resources to implement the plan.
Journal clubs are a popular forum for teaching research methodology and critical reading skills. Review
the organization, attendance, and format of these sessions. Determine if there are any other teaching
activities (e.g., workshops or seminars) that the research director organizes. There should be clearly
defined plans for funding, supervising, and staffing existing research fellowships. The role of the
research director in training should be specified. If there is a fellowship planned, there should be
agreement on the timetable for establishing the funding mechanisms, recruitment, curriculum
development, and duties of the research fellows.
Adequate support staff is a necessity. Negotiate for funding of research assistants, technicians, nurses,
and secretaries, along with support for medical student research projects. The amount of secretarial, data
management, and technical support to be available are critical. It may be desirable to negotiate for a total
research budget to be managed by the research director.
There should be adequate computer hardware and software support along with access to hospital
databases for demographic and retrospective studies. Ideally, the mainframe statistical and data base
programs are available and usable without requiring support by information services. There may be
charges for mainframe time and, if so, funding for this must be established. Computers and software
quickly become outdated, so an information systems budget should also be negotiated. Because statistical
analysis is a specialized field, the availability of outside statistical consultation is a necessity unless the
department employs its own statistician. A statistical advisor familiar with clinical research should be
available, along with departmental funding to pay for that service. Not all necessary resources may be
available at the institution. The departmental chair may be able to identify resources such as
biostatisticians, epidemiologists, physiologists, or other support at cooperating institutions.
A final step is to evaluate the ED volume and diversity to ensure that there is an adequate base to support
a successful clinical research program. Areas of particular research interest such as pediatrics,
toxicology, resuscitation, trauma, or prehospital care require a specific mix of patients in order to
complete trials in a reasonable period of time. The hospital or billing service database can be used to
retrieve a listing by ICD-9 code of patients that fall into specific areas of interest.
It should be possible for most EM residents and junior faculty to start small, focused research projects
with local funds, thus avoiding a formal grant process. Few residency programs have developed major
sources of extramural funding, and the availability of local funds should be part of the initial job
negotiations.
Lastly, establish how faculty are evaluated. Since the requirements for tenure vary, the formal written
tenure rules should be reviewed as well as the actual achievements expected by the P and T Committee.
The expectations for tenure and promotion in a research tract may vary from those in a teaching tract.
Aside from tenure requirements, determine how the department sets expectations and bonuses, whether
by grant support, number of papers, appointment to national committees, or resident teaching. Commit
the director to achievable goals and determine what level of performance will be considered
unacceptable, and conversely, what level will be considered superior. Make sure your position is
challenging, personally rewarding, and supported by adequate resources.
Barriers to Conducting Clinical Research*
Lack of Interest in Research by Staff
Lack of Meaningful Research Organization
Lack of Interdisciplinary Support and Collaboration
Patient Recruitment Problems
Clinical Priorities Impede Research
Lack of an Adequate Patient Base
Delays in Institutional Review Board (IRE) Approval
Data Retrieval Concerns
Lack of Expertise and Equipment to Process Data
Non-productive Statistical Analysis
*Presented at the third annual Research Director's Luncheon, 1990 SAEM Annual Meeting.
Research Director
Administration
Responsibility
Resources
Benefits
Negotiating a Departmental Chair Position
Negotiating for the position of chair is different than negotiating for any other faculty level position in
that one is negotiating not only for yourself, but for the department as a whole. The role of chair is
fundamentally different from that of junior or senior level faculty. The chair is both a leader and a
manager within the department and, yet, a faculty colleague. Solomon Papper, MD, in his book "Thirty-Five Years in the Tower", describes well the attributes of departmental chair: "A chair should be a
leader. They should be inspiring and inspired individuals who will recruit others to take care of 'things'
while the leaders focus on people. A chair must set the tone or atmosphere which should be one of
fairness, intelligence, and respect for those in the department. A chair must serve to recruit people to the
department who are 'better professionally' than they are. A chair must enjoy basking in reflected glory
rather than in glory of their own. And, finally, the chair of a clinical department should be and remain a
first rate clinician, teacher, and have a positive view of and experience with personal academic
scholarship." Further information regarding the role of chair can be found in the excellent book,
"Chairing the Academic Department: Leadership Among Peers," by Alan Tucker.
For the position of department chair, a number of scenarios are possible: One may be: (1) in the same
institution with a newly created chair in emergency medicine; (2) in the same institution with prior chairs
in emergency medicine; (3) in a different institution with a newly created chair in EM; or (4) in a
different institution with a previous chair in emergency medicine. Negotiating in an institution which has
never had a department of emergency medicine has both certain advantages and disadvantages. Since
there is no prior model or expectation, all areas are free and open to discussion. However one may be
forced into a departmental mold that exists for other departments with a lack of understanding of the
needs of emergency medicine. The chair candidate will then need to work harder to provide a realistic
and objective plan for the needs of the new department of emergency medicine.
During the interview, determine which committees have influence over credentials, hospital
appointments, medical staff/administrative coordination, Board of Trustees relations, billing, salaries, or
other resource allocations. It will be essential to insure representation of Emergency Medicine on these
committees. Determine the make up of the dean's executive committee or medical school steering
committee. It is also appropriate to review access to hospital and medical school committees where one
would want to be involved, such as the promotion and tenure committee and medical school curriculum
committee.
The scope of nursing practice must be compatible with modern ED operation including the initiation of
thrombolytic therapy and recovery from conscious sedation. Similarly, the Chair must have appropriate
influence over the ED clerical staff to assure timely support for paperwork, documentation and billing.
The Emergency Department administrative structure may have separate lines of authority for the clerical,
nursing, and medical staff. Determine the level at which these groups interact to resolve operational
problems and insure that the ED Chair will have final authority over operations. Secure a budget for
EMS coordinators, trauma coordinators, secretarial staff, research assistants, and billing personnel.
The functioning of other ancillary personnel, such as radiology, laboratory, or EKG technicians may not
be under the Chair's control but their effectiveness may be evaluated by reviewing quality assurance or
time studies. The Chairs of these departments may welcome the opportunity to improve their own
services in support of the ED. One of the keys to the Chair's success will be the views of other Chairs
and their flexibility towards clinical practice in the ED. Discussions with these Chairs will reveal their
understanding of emergency medicine. Their views may be a result of concerns such as their own
residents' education, the need to protect turf, or financial issues. Identification of a few critical areas
such as trauma care, the emergency care of children, or emergency ultrasound may allow for resolution
of these issues during the negotiation process, particularly if a third party, such as the Dean or hospital
president is able to broker an agreement.
In many hospitals there is a dominant department, whose Chair holds considerable influence over the
direction of the institution. This individual must be identified and be supportive. Meetings with other
Chairs should eventually result in agreements that give EM faculty the authority to admit patients,
appropriate clinical privileges for procedures and timely consultation services (Table 2). EM residency
programs require support from Surgery, Medicine, Pediatrics, and OB/GYN to provide inpatient
rotations and to insure that EM residents manage critically ill and traumatized patients. This support
should be established prior to accepting a position.
The "honeymoon" period will be short lived, so major expense items should be addressed before
accepting a position. Other items of importance include major equipment for the department, expansion
of the nursing or ancillary support staff, and commitment of funds to the residency program.
The hospital's financial staff can provide information on the budgetary process and the manner in which
priorities are set. They may give information on the financial strength of the hospital by providing such
data as the hospital's credit rating, cash flow, and size of the restricted and unrestricted funds. Part of
this information may be publicly available if the hospital has recently issued bonds.
Academic hospitals handle professional billings and collections in several ways. When the hospital bills
and retains professional fees within its general fund, there may be the opportunity for an incentive
arrangement. The Chair must oversee the manner in which professional fees are set and generated. Each
academic department may run a professional corporation and under this arrangement the hospital may
agree to provide guarantees or other legal or financial assistance for establishing a corporation. Lastly,
many academic centers run under the control of practice plans. These practice plans may be departmental
in which case established plans should be reviewed to determine whether there are essential changes that
must be made. The fund balances, accounts receivables, and current obligations of the practice plan
should also be reviewed. Determine the medical school budget and the practice generated income
available to the chairman. The Dean may agree to provide research monies or stipends for medical
student teaching. Conversely, the nature of the affiliation may be such that the department must pay a
Deans tax" from practice earnings.
For laboratory investigation, adequate space is critically important for developing departments.
Minimum laboratory requirements are in the 300 to 500 square foot range, while 1,000-2,000 square feet
is ideal. This should include office space for research technicians and research-oriented faculty.
Keep in mind that you have a position of considerable responsibility and authority. Be creative and bold
in developing your "wish list". Items which you may consider difficult to obtain may be easily granted
by the Dean or hospital president.
Chairs Position
Institutional Issues
Academic Issues
Interdepartmental Relations
Medicine
Pediatrics
BASIC PRINCIPLES OF NEGOTIATION
Stage II - Exchange of Information: they talk about it.
Stage III - Reach for a Solution: the two parties arrive at a mutually acceptable solution with each side
compromising as needed. The traditional view is that the winner is the party that compromises the least;
however, more people now realize that in a long-term relationship there is no "winner" if one party feels
it has lost.
The essence of win-win negotiation is trust and open communications. Mutually beneficial solutions can be
arranged when both sides understand the needs and concerns of the other. For example, a new faculty
member may want more salary than the chair is comfortable with, but in exchange may be willing to work
all night shifts. A prospective research director may settle for fewer nonclinical hours if promised a research
assistant. Only when there is enough exchange of information in stage II of the negotiations can these
arrangements be created. Solutions only become obvious after enough information is available. The
importance of mutual trust in exchange of information cannot be overemphasized, but it can be difficult to
decide how much to reveal. Ideally both parties would reveal the deadlines and minimum settlement point
on each issue, but there is a tendency for initial positions, even if offered as an absolute minimum settlement
point, to become the starting point for compromise. The balance between these positions depends on the
trustworthiness of the negotiator's partner, as assessed during the Stage II discussions.
Separate the people from the problem. Focusing on problem solving rather than personality helps to maintain
relationships during intense negotiations. Show respect for others even if they take a disagreeable position.
Similarly, friendship or loyalties should not interfere with a negotiating process focused on problem solving.
Stage II of academic job negotiations
IV. Clinical Duties
for an academic position
The single most important factor to consider is the number of clinical hours required of you as a faculty
member since this will dictate the time available for academic pursuits. In general, 20-24 clinical hours per
week allows adequate time for research, teaching, and administrative responsibilities. In the case of a clinical
teaching position, where little or no research is required, a 30 to 36 clinical hour schedule is probably
appropriate. Senior faculty with administrative, teaching, or research responsibilities should expect to spend
one to three days per week outside of clinical duties and the number of clinical hours to be negotiated will
depend on the nonclinical goals agreed upon during negotiations. The distribution and length of the shifts
may be more important to senior than junior faculty. Current faculty may indicate if they are satisfied with
the shift distribution or if some faculty get preferential treatment. The distribution of night and weekend
shifts may also reflect the attitude of leadership toward equity in other affairs. The total number of clinical
hours may be more important than shift length to most junior faculty. Shift work effects health and family
life and may becomes more difficult to tolerate, both physically and psychologically with age.
ED operations may be funded from many different sources including the medical school, hospital, medical
practice plans, and grants. Faculty should understand these sources, their stability, and the history of
funding. The funding should be adequate for both ongoing clinical operations and purchase or replacement
of capital equipment. The salary budget should allow for cost of living increases as well as merit raises or
bonuses. Funds should be provided for CME, dues, journals and textbooks. A research budget may provide
seed money for junior faculty. It is important to understand the linkage between patient care income, the
departmental budget, and your physician salary. Determine who has control of the budget, how your salary
is set, and how raises are negotiated from year to year.
Review the relationship between emergency medicine, the hospital, and the medical school. The real
authority may lie with the ED director, an administrator or chair of another department. It is crucial to have
a full-time ED chair with a direct reporting relationship to hospital administration in order to help insure that
adequate resources are available for faculty development. It is essential to determine if the chairperson of
emergency medicine has the authority to effect needed change and will support faculty in disputes with other
departments. If EM is not a separate department but is a division within another medical school department,
there needs to be active support for EM by the parent department. In that instance, a personal interview with
the academic chair will determine their views about emergency medicine practice and research. The chair
should have sufficient local authority to advance the EM program.
Responsibilities apart from teaching and patient care are often ill-defined for junior faculty.
Administrative duties, while required of most senior faculty, can encroach on academic and teaching time.
Discuss the extent of such responsibilities, along with the authority given for and rewards of such service.
Expectations for administrative duties should be negotiated prior to accepting a position.
Academic expectations vary for university based and community based programs. Medical school positions
typically require less clinical practice with greater expectations for teaching and research. The advantages
of this type of position include greater contact with medical students, and direct involvement with other
medical school departments. The salaries in academic practice may be 25-50% lower than in community
programs. There is usually less pressure and opportunity for research in a community hospital, but a greater
emphasis on patient care. Requirements for clinical practice, teaching, and research and publication vary
widely, however, and these expectations should be established prior to accepting a position.
The need for career development for faculty cannot be overemphasized. The presence of senior faculty
mentors within the department is vital for career growth. Departmental commitment to the development of
faculty should include sharing of opportunities for research and publishing and attendance at career
development mini-courses or fellowships.
It is impossible to perform well as a faculty member without adequate secretarial support. Job negotiations
should consider a budget for computers, books, software, dictation and other needed equipment. It may be
desirable to request a yearly discretionary allowance.
The process of obtaining an academic position begins with defining short and long term career goals. Other
factors such as economics, geography, family needs, and job satisfaction should be assigned relative weight.
This will identify the type of position and institution on which to focus a search.
Personal Issues
The central issue is the commitment of the institution to the training of emergency medicine residents. A
statement can be found in the Institutional Policy Review Document required by the ACGME
institutional review, which states its reasons for sponsoring graduate medical education, describes the
process by which educational resources are distributed, and details the system by which resident
positions are apportioned1. The most recent ACGME institutional review will point out the strengths and
weakness of the institutional GME program.
There must be an adequate number of faculty budgeted for the department not only for patient care and
resident supervision, but to allow for activities such as didactic teaching, research and publication,
administration, and committee assignments. The actual number required to adequately staff the program
will depend on such factors as patient acuity, ancillary support, and size of the EM program. A recent
survey4 of EM programs found that there were an average of 11 full-time and 4 part-time faculty
working an average of 23 hours of clinical time, 19 hours administrative and teaching time, and 7 hours
per week in research. Some programs also have an associate or assistant residency director, a research
director, or a local site director, depending on the size of the program.
A program director must have authority to direct the educational activities of the department and to
implement changes to meet evolving needs of the residents and requirements of the RRC. This should
include enough influence over ED operations, teaching faculty recruitment, continuous quality
improvement, and policy making to the extent these functions affect residents. There will be limits to the
authority of the residency director relative to the departmental chair. Part of the negotiations should
include a frank discussion on those limits and the means by which conflicts will be resolved. This should
include a discussion on the process of selecting an associate residency director. Determine the role of the
other faculty in setting residency policy. There may be an overlap between the responsibilities of the
residency director and those of the research director, EMS coordinator, and medical student coordinator.
Find out what understandings are currently in place regarding specific areas of the program and
mechanisms for resolving conflicts. One area of potential conflict is resident scheduling. Determine how
the inevitable conflicts between the service needs of the department and the educational needs of the
residency program are settled. In summary, determine the authority of the residency director and the
latitude of the departmental director.
The residency director's duties should center on program development and resident recruitment,
retention, and advancement. Direct patient care and supervision of residents in the ED by the program
director provides both a role model for the resident and allows the program director to monitor the
residents' performance, training and experience first hand. Responsibility within the department and
hospital for activities related to resident training should be balanced against the director's other
responsibilities, such as didactic teaching, research, and publication. The program director's schedule
should allow time for resident conferences and counseling. The program director must have time to
participate in national organizations and it will be difficult to perform all these duties if more than half of
the time is spent in clinical practice.
There must be funds and time allotted for not only CME, but also attendance at national meetings and
committee work. While there may be a set number of CME days that are allotted to faculty members,
the residency director may want additional time to attend pertinent meetings of the AAMC, SAEM,
CORD, and ACEP. In addition, determine whether time away from the institution for national
presentations, participation in organized emergency medicine courses or activities as an RRC site
surveyor or ABEM board examiner are counted against CME time.
The same questions apply for new EM program applications. Under these circumstances it is essential to
determine that the institution understands the nature of its commitment and the impact this will have on
other areas of operation. Most programs are not approved on initial application, and the long term
commitment of the department to a residency program must be assured.
The central issue to be assessed is the extent to which the institution promotes and facilitates the training
of emergency medicine residents. Negotiations should be focused on the areas that are essential to
furthering the development of the program.
Status of the Residency Program
Residency Director's Authority
Responsibility
Residency Program
Resident benefits (health, vision, dental, disability insurance)
Recruitment costs brochures, postage, meals, lodging)
Resident meeting and travel expenses
Funds for journal club meals and graduation party
Resident research fund
Books and journal subscriptions for residents and library
Computer hardware and software
Slide making equipment, photographic supplies
AV supplies (slide and overhead projector, medical illustration)
Secretarial support
ACEP and SAEM dues for residents
ACLS, ATLS, PALS, BTLS fees
Outside supplies and fees
Educational materials (models, prepared slides, computer simulations)
Speaker's fees and honorariums
Sir William Osler noted that, of the three traditional duties of an academic department, scientific
investigation was the first to suffer when resources were strained. Research directors find that their other
roles as faculty constantly encroach on whatever time is available for investigation. Not only must
directors conduct their own work but they must create an environment that fosters departmental research.
Research directors need the support of their directors, fellow EM faculty, and collaborators in other
departments, in order to succeed. Without a cooperative environment, efforts to create a research
program will fail (Table 1).
Most academic programs have university and hospital relationships. These relationships and their
interconnections will give insight into the commitment of the institution to emergency medicine. It is
difficult to maintain a serious research program without medical school and university affiliations which
facilitate liaisons with basic scientists to collaborate or consult on one's projects. Ideally the basic science
departments will have expertise in areas of interest within emergency medicine such as toxicology,
epidemiology, or cardiovascular physiology. Ideally, emergency medicine should be an independent
department. For the research director, the advantage of departmental status is greater access to labs,
graduate students, or membership on university committees. In addition, there may be institutional grants
or awards that are available only with adequate support from the academic chair. In the absence of
departmental status, the chair of the parent department must commit active support to emergency
medicine research.
The chances for academic success are greatest if the existing program is broadly established with a
critical mass of committed faculty who are actively involved in research. The potential applicant should
identify key faculty members and analyze their specific academic interests and record of
accomplishments, including grants and published research. Concern should be raised if the research
director is the only faculty member actually doing research. More specifically, a departmental director
who lacks research experience will have little insight into the resources and time necessary to conduct
quality investigations. In a department that has a commitment to research, there will be a requirement for
at least a group of the academic faculty to conduct research. Inclusion of research achievements into the
departmental bonus system and the number of faculty in tenure track, if available, provide additional
evidence of departmental commitment.
The structure of the training program including educational objectives, resident research requirements,
and the amount of time available for resident research should be reviewed. The support for resident
research will be evident in the scope of resident publications and presentations. There must be an
agreement with the residency director on the expectations for the research director's involvement in the
training program. This agreement should cover resident research requirements, support for resident
travel to present abstracts, availability of designated research blocks, and funding for resident projects.
The research director should have specific responsibilities for resident training in research. The program
should have an established research curriculum that specifies how those goals will be met. The research
director may be asked to supervise all resident projects, which will require a significant commitment of
time. Alternatively, if the general faculty precept the residents, there must be some provision for
insuring that the resident role is meaningful and properly structured. Conflicts may arise with other
faculty over assignment of residents to specific projects, authorship of resident projects, and
responsibility for review or preparation of grant applications. Discussions with other faculty and with
senior residents may clarify how these issues have been handled previously.
Clinical and administrative demands cumulatively greater than 24 hours per week can make it difficult to
maintain a functioning research program. There must be flexibility in scheduling to allow for consistent
research day(s) for animal lab scheduling or to schedule larger blocks of time for concerted efforts on
grant or manuscript preparation. Protected research time should be negotiated separately from other
types of nonclinical activities such as conducting departmental research conferences, reviewing
manuscripts, and attending committee meetings.
Other resources that are critical to a successful research program include adequate office space, research
facilities, and staff support. A quiet, well-equipped research center within or contiguous with the
emergency department can be a powerful incentive for the production of grants and study protocols. The
basic science laboratory ideally should be in proximity to the hospital. The animal care facilities must
meet Federal (NIH) standards and have provisions for long-term care and postoperative recovery,
preferably supervised by a veterinary surgeon or technician.
Determine how the existing research program is supported and review the record of grant support. There
may be institutional seed grants, or funding available for new investigators. The institution's foundation
may have access to other funds for specific projects. The departmental chair is in the best position to
acquire institutional support for the recruitment of a research director. Resources such as start-up funds,
secretarial support, and lab space may be controlled by a specific administrator or research committee.
The chair may use the department's needs to hire a research director as leverage to obtain these items.
Keep in mind, however, that this requires a commitment on the part of the chair to expend the political
capital necessary to obtain these resources. Since the chair may have other areas requiring attention,
there must be a demonstrated need for these resources.
Research directors require opportunities to acquire new skills and knowledge to maintain their
effectiveness. Such faculty development opportunities include time to pursue advanced degrees or funds
to attend research, statistical, or other appropriate seminars. Determine if any discretionary funding is
available for academic expenses, such as journals, software, reprints, small equipment, or society dues.
The CME and travel budget should provide for personal CME conferences as well as research related
meetings. Determine how it is decided which faculty attend a particular conference.
Two determinations have to be made prior to the negotiations for a position as Departmental Chair. The
first is the personal priority for goals such as research, a residency program, institutional influence,
prestige, impact on medical school curriculum etc. The second is the institutional goals and objectives
and how Emergency Medicine fits in with those plans. The secret to successful negotiation, and success
as Departmental Chair, is to use the institutional strategic goals to meet personal and departmental goals.
The Chair should have final authority over Emergency Department policies and procedures. The Chair's
ability to administer the Department will partly depend on how the Chair's position fits in the
institutional hierarchy. There will always be limitations to a chair's independence and part of the
interview with administrators and the dean should be devoted to defining limits. If the Chair's
responsibility is to administrative channels, ensure that there is access to senior administration. Candid
discussions with administrators and other Chairs should be directed toward identification of key players
on the staff and the process by which the institution functions. Ability to expand the department and
achieve departmental goals will depend upon both the formal and informal authority given to the Chair's
position. That formal authority should include a hospital department seated on the same basis as other
clinical departments. The informal authority will depend on the ability of the chair to work with other
key individuals.
Adequate number of nursing and support staff are essential for the operation of an ED. This number can
be estimated by surveying departments of similar volume and acuity. Negotiations are an opportune time
to advocate for an appropriate staff budget based on those surveys. The Chair's relationship with the
Emergency Department nursing manager will be key in influencing changes and direction of the
department. The Chair should have the opportunity to evaluate the nursing manager's performance.
This is the time to secure budget support for recruitment of EM faculty. Negotiate for an adequate
number of staff to meet the clinical, teaching, and research missions of the department. Projections on
faculty numbers should be based on limiting the faculty clinical time to 20-30 hours per week. The
faculty will require research space, academic appointments, opportunities for promotion, and protected
non-clinical time. There must be adequate office space, secretarial support, office equipment, computers,
and other supplies. There should be a secretary for every three to four faculty members with additional
support for the residency program and departmental chair. Ideally, the negotiation will result in a
sizeable research seed fund from the institution, along with research assistants and laboratory space.
The nature of the university affiliation and the Chair's role with the university should be determined.
The hospital president may be willing to influence the dean of the medical school to establish an
appropriate status for Emergency Medicine at the university. Determine the nature of the proposed
academic appointment, requirements for tenure, availability of appointments for other EM faculty, and
the process for advancing those appointments through the university. Explore the opportunities, or
obligation, to serve on university committees and faculty councils which influence the medical school
curriculum and the access of emergency medicine to medical students. Curriculum time is closely
guarded by long entrenched departments, but this is an opportunity to negotiate with the dean for
Emergency Medicine time in the curriculum.
Chair's salaries vary widely depending on the nature of the institution, the professional fee billing
arrangements, and geographic area. Salary ranges may be available from recruiting agencies, SAEM,
AAMC, or by discreet inquiry among other Chairs within the Chair's region. In general, the chairs
salary should be 150-200% higher than that of faculty. Other benefits include insurance such as vision,
dental, medical, life, and disability. Moving costs may be substantial and any limitations on the types of
moving services which can be engaged should be discussed up front. There must be some discretionary
funds provided for seed grants, recruitment, travel, dues and subscriptions, research, or other academic
purposes.
There will be many items on the wish list during negotiations. By establishing priorities and ensuring
that the essential items are granted in advance, future obstacles can be minimized. Increased institutional
commitment up front will bode well for the future of the department.
Issues to be Discussed During Interviews
Institutional strategic goals and objectives
Role of Emergency Medicine in meeting institutional goals and objectives
Short and long term goals for the department
Role of the Chair in institutional decision making
Opportunity for departmental growth in occupational medicine, hyperbaric medicine, toxicology,
urgent care, etc.
Determine how institutional priorities and budgets are set
What are the risks and rewards of entrepreneurship
What is the hospital president's vision of an ideal department
What are the strengths and weaknesses of the institution
What is the mission of the institution and how is that mission accomplished
What role can Emergency Medicine play in medical student education (didactic lectures, clerkships,
BCLS courses etc.)
What is the school's plan for achieving academic excellence
What are the major research initiatives of the school and how can Emergency Medicine contribute
towards those goals
What is the dean willing to do to promote an EM residency, academic department, medical student
clerkship etc.
How does promotion and tenure work, what is it's practical importance, and how will EM
research/teaching/service be viewed by the promotions committee
General
How are admissions handled
How are disputes about admissions resolved
How many residents are assigned to the ED
How are private patients managed
What rotations are available for the EM residents
Are consultants available on a timely basis
Is there adequate follow-up for ED patients
Are there conflicts regarding clinical privileges for procedures performed by both EM and other
specialties
Surgery - Who manages trauma resuscitation
Are there restrictions on the procedures that EM faculty can perform
Who can approve interhospital transfers
What processes are in place to handle bed shortages
Who has final authority to admit to an ICU
Who controls observation beds
Who manages pediatric resuscitation
Are neonatal resuscitation handled differently
OB/GYN - How are sexual assault evaluations and women > 20 weeks gestation managed, Is gyn
ultrasound available after hours
Radiology - Are radiologists available after hours
Are special studies available
Can EM faculty perform ultrasound
Anesthesia - Are there limitations on privileges for intravenous sedation or rapid sequence intubation
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