Joining a Practice: A Practical Guide

Jeff Zimmerman, Ph.D.

The Practice Institute

[ADDENDUM: If you're interested in this topic, see Dr. Zimmerman's webinar, recorded in December 2015]

Joining an existing practice can be daunting. You're looking for them to hire you (you hope) and feel at the mercy of the interviewer(s). How can you prepare? How can you get a sense of the practice? How can you negotiate when it seems they're holding all the cards? This practice guide will walk you through some of the key considerations and options for dealing with the process of joining a practice.

You can consider this as a 4-step process :

1. Getting the interview

2. The interview process

3. Negotiating the agreement

4: Signing the Agreement

Each step has its own challenges. Here at TPI we will take you through these challenges and give you ideas about how to best deal with them. So, here we go.

Getting the Interview

This can be quite challenging. While professional publications may have ads, these may be placed to meet hiring policies and not be true solicitations.. Additionally they may be two months old or more (as they might have to be submitted far in advance of the publication date). Perhaps the best way to get an interview for a private practice is through networking such that the practice actually invites you to interview. Amazingly, this can occur even if they don't have a job or opening posted. That's right. Many practices often have their radar up for opportunities to bring someone on board they believe will be a good fit. If they think you might be one of those somebody's, you may be able to be recruited and in the door for an interview without applying for a specific position at the practice.. So, what are some steps to getting found by the practice?

- Research: Spend some time researching the professional practices in the area you wantto work. Find out about their demographics (e.g., size, number of offices, who worksthere, who are the owners, what specialties do they serve, etc.). Most of this informationis on-line if they have a website. We recommend that you look at every website of everyprivate practice that you can find in the geographic area. You never know what willappeal to you until you exhaust the possibilities.

- Connect with people: This is perhaps one of the most powerful ways of networking. Join your local professional association(s). Go to meetings, get on committees, and start talking and asking questions. Ask people where the good practices are (and why), do they know of practices who are looking for someone, and find out what needs are present in the community that you might have an interest or ability in filling. If you get a lead, be sure to ask, "When I contact ________, may I feel free to use your name?" If you get a "Yes" be sure to do so when you first contact that individual. It can go a long way to getting a response back.

- Reach out and be receptive: One way to get noticed is to contact people who are practice owners and ask them if you can have a short amount of time to just get to meet them (by phone or in person) and find out a little about their practice. You don't have to be ashamed to say you are thinking of joining a practice and that you are trying to talk to a number of local practices, even if they don't have a particular position open at this time. Sometimes that kind of statement might get you a 15-30 minute meeting. Make no mistake about it; this meeting is an interview. It is a chance for you and the practice owner(s) to get to know each other and size up the question of fit (one of the key objectives of the interview process). Do your research first, so you know what questions to ask and what you can offer that might be of interest to the practice. Keep the tone casual and professional. At the end of the conversation, be sure to ask them for leads on anyone else you might call (unless of course they ask you to come for a formal interview) and whether or not you may use their name.

The Interview Process

As much as we'd like to think of the interview process as an objective one, many Human Resource Directors who are professionals in acquiring talent for their companies will speak to the subjectivity of the process and the number of poor hires that occur over time. Your colleagues who own a practice are not necessarily trained in interviewing and hiring professionals, but yet need to out of necessity. Perhaps worse than not getting the job, is getting the job, passing by other possibilities, and then finding out that the fit was poor (on either your part or theirs). Consequently, the interview process, from start to finish is an opportunity to gauge fit across many different dimensions on both the parts of the practice and your own.

As stated in the first module, the interview process begins from the very first communication with the employer. This occurs before the actual formal interview. Many interview opportunities are lost due to phone etiquette, lack of professionalism in responding to an advertisement, and even the firmness (of lack there-of) of a hand-shake (As ridiculous as this may sound remember that this is a subjective process).. Many employers may view every interaction as an opportunity for you to say something about yourself, and as an indication of how you might represent them should you indeed join their practice. Going out to lunch or out to dinner is not simply sharing a meal. It is another sample of professional behavior for them to observe. If you drink alcohol do not have more than one drink. If they are treating do not pick the most expensive item on the menu. The interview process is your opportunity to put your best foot forward and to show them what value you bring to their practice, beyond that of the other candidates.

The Numbers Game

One way of looking at acquiring a job is as a numbers game. The only problem is you don't have a clue as/to the odds. You may be the only candidate for a position that does or does not yet exist, or you may be 1 out of 100 candidates. The trick is always focusing on bettering the odds and separating the consideration of you as a candidate from the others in a positive way. Keep this in mind throughout all your contacts with the potential employer.

This also means not focusing all of your energies on one practice. Interviewing with as many practices as possible only increases your options. You don’t owe the practice that you are talking with the loyalty of not talking to other practices just as they don’t owe you the loyalty of only interviewing you to join their group.

Giving Them What They Need

Presumably there are other people who the employer can seek out that have the same number of years of experience as you. Don't be ashamed if you are in the early stages of your career, or are in the middle or late stages of your career. You have something to offer that can set you apart from other applicants. The key is figuring out what you have to offer. Is it a unique set of skills, a work ethic, an ability to be flexible in types of treatments, patient or work schedules? Is it your ability to address a particular need faced by the practice?

If you do your research about the practice in advance (even carefully reading their website) you can get an idea of what the challenges are they may face or where their gaps might be in service delivery. You can also softly query them about the practice. In their book Financial Success in Mental Health Practice Walfish and Barnett (2008) offer a long list of potential questions to ask when joining a group practice. These may be found at the end of this practice guide. One question that can be particularly useful, but not very threatening is an open-ended one such as, "What challenges have you faced as a practice in the recent past?" The answer and the way the question is addressed can give you a sense of the openness of the employer and challenges faced (e.g., in service delivery, meeting the needs of the community, internal structure and culture, etc.). Going into the interview with a few well thought out questions can help you compare positions and also fill those awkward moments of silence that can develop. The more the interviewer speaks about the position, the more clues you get about fit and what you might have to offer that can set you apart from the other applicants in a favorable manner.

As the interview progresses and you get more information about them (while in the process of telling them about yourself) you can begin to think about what you have to offer that can actually enhance their organization in some way. Ask yourself the question, "If I was the interviewer, why would I want to hire me?" Then, offer up that information in the context of answering some of the questions posed to you.

Be careful though. Interviews have been known to explode when the candidate poorly assesses what the interviewer is seeking in a hire. An example of this happened, when a prospective employee stated that one of his strengths was that he was quite good at keeping patients in treatment. He incorrectly believed that this was important to the interviewer, when what actually was important was providing the right amount of high quality treatment. At that moment, as far as the interviewer was concerned the interview "exploded" and there was no possibility of recovery. The interview politely continued until its natural conclusion, but the interviewee was ruled out following that one comment.

Instead, try to "Wow" them with something that will be unforgettable and make them say to themselves, "We really need to get this person to join us." That sets you apart in a positive light, improves your odds and can help you progress towards getting an offer.

Getting What You Need

The interview is an opportunity for you to assess the employer as well. A bad fit can cause you to pass up other opportunities and be very disruptive to your life. It can also leave you in a position of having to explain your decision during the subsequent series of interviews that occur when you are again in the market of trying to affiliate with another practice. So, all of your clinical skills come into play here. At the same time that you are being personable and confident (but not arrogant) and are answering their questions in a clear and direct manner, you are in the process of assessing if this is where you want to practice. Be attentive to what their choice of questions tells you about what is and isn't important to them. How much are they interested in your needs? What do they emphasize about their practice and the working environment? What isn't spoken about?

Try to get a sense of what it is going to be like working there. How much autonomy will I have? How much peer support and administrative support will I have? Is this a culture in which I will feel comfortable and be able to grow professionally or not? Assess how the staff you meet look. Are they smiling? Do they make eye contact? What are the physical surroundings like? Does it seem like a reasonable amount of money is being spent on the furnishings and infrastructure? All of this is information to sift through in terms of trying to assess fit. Speak to other professional employees at the practice. You can ask to do this - even if it is just for a 15-20 minute interview. And, remember... they too are interviewing you, while you're interviewing them.

What about an equity stake in the practice, or said another there an opportunity for you to be a partner? This can be a touchy area for the employer, but you can get a sense of your long-term investment in the practice and what the process is of turning the job into something that gives you a chance at ownership. Too many people join a practice by focusing on the initial terms of the agreement. However, will the terms and your role in the practice remain the same 5-10-15-20 years later if you remain with the practice? While this may be difficult to imagine, the agreement that you sign entering a practice will set the stage for years to come.

Honing Your Interview Skills

If you want to hone your interview skills you can go on "practice interviews" at professional association job banks. These may be 10-15 minute interviews, but they can help you work on your skills at sizing up the practice and having a professional discussion that is not riddled with obvious anxiety. If you are practicing in the same geographic area where you received your degree many career counseling services at universities offer coaching on job interviewing. This may include videotaping and providing you with feedback on both your verbal and nonverbal behavior. You can even practice interviewing with friends who are in the field, letting them ask you difficult and also predictable questions. You can, for example, especially focus on questions related to particulars about your resume. You also should be prepared to answer questions about your strengths and weaknesses (perhaps showing an understanding of your "weaknesses" that could be viewed as a strength of insight and character to the interviewer). It is important for you to understand where you need further growth as a clinician, especially if you are recently graduated. Practices do not expect early career professionals to be fully polished and clinically adept in all areas.

One very telling question on an interview comes when the interviewer asks you to describe a case. Be prepared. Think in advance about a case to describe that will showcase how you think and work. You might want to think about a "success" and also a case that you struggled with and to know why you struggled. Often, the interviewer may be looking at how cogent your thinking and description of the case is, and how sophisticated your understanding is (more than your theoretical approach, or whether it was a glowing treatment success) when working with clients. They want to know they can trust your clinical judgment,

Some Additional Advice

If you're thrown in the interview, don't try to fake it. Remember, you are being closely evaluated by a mental health professional. If you give the interviewer a sense that you're not genuine, or trying to fake it, why would they want to hire you? It can be very effective to pause, say "That's a really good question," and then think a moment before giving the best answer you can.

Remember, the key to the interview is giving the interviewer a chance to see your best side, so don't be shy. It is also a chance for you to assess the fit as you see it with this employer. A very successful outcome to the interview can be either achieving clarity that this is a place you do not want to work, or getting a subsequent offer.

Negotiating the Agreement

Congratulations! You have an offer. Now what?

There are some key questions to ask, both of the practice and of yourself.. In fact, one could say that now you have the opportunity to ask some very specific questions to continue to assess the fit before you make a final decision. Keep in mind though, that there is no rule against asking some of these questions during the interview process, especially if you are called back for a second interview. Often second interviews are actually subtle negotiations of the terms of the employment contract, as you both see if the fit can extend to the formalities of the business relationship.

Some categories of questions for the employer are as follows:

Compensation: How are you getting paid? Are you a regular employee or a sub-contractor. If you are a sub-contractor be sure to check with your accountant to make sure the designation is appropriate. This is important to do because some group practices label you an Independent Contractor to save on expenses, but at the same time expect an employer-employee relationship. Remember too, as a sub-contractor you will need to pay the employer contribution of Medicare and FICA taxes, there-by reducing your net take-home pay by approximately 8%. Is your income fixed or are you paid a percentage of monies collected for the services that you provide? Additionally, determine if you are at risk if you are less productive, if there are cancellations or if there are snow days. There are not right or wrong answers here. Rather, it is a question of continuing to strive for clarity so there are not assumptions which can lead to disappointment later.

A general rule-of-thumb is that the more risk one takes the more the potential rewards should be. So, if the employer is guaranteeing more of your compensation and paying for more benefits, then it is likely your salary will be less.

Be sure you're clear about what the employer is offering and how your compensation will be computed, e.g., number of hours worked, percentage of dollars billed, percentage of dollars collected, etc

Benefits: If you are an employee (as opposed to an Independent Contractor) you may be entitled to certain benefits of this employment. There are many benefits to check into. Some of these are as follows:

- Health insurance: What does the policy cover and what is your contribution towards the premium?

- Disability insurance

- Life insurance

- Workers compensation insurance

- Malpractice insurance

- Participation in a retirement plan

- Paid vacation time and other holidays, sick days, personal days

In addition to the above benefits will you be receiving these professional service or opportunities?

- Furnished office space

- Testing and other professional equipment, as well as stationary and business cards

- Funding for CEUs and professional conferences

- Professional memberships

- Administrative and billing-collecting support

- Marketing initiatives

- Case flow and referrals to you that are generated by the practice

- Opportunities to have some equity in the practice and to be involved in the decision-making process

Here again there aren't right or wrong answers. The key is making sure expectations are clear.

Job Requirements: Equally important as what you're getting (compensation and benefits) is what you're giving. Be sure you understand what the employer is expecting in terms of things such as:

- Your caseload

- Your attendance at meetings in the practice

- The expectation on you to generate your caseload and market your services

- Your need to be on-call

- Administrative requirements (e.g., charting, participating in managed care, following-upon your accounts receivables, etc.)

Independence and Autonomy: This is a continuum and varies based on the practice and your own professional development. How free are you to make your own decisions (clinical and otherwise)? How much supervision is available and how is it structured (one-on-one time, group supervision)? Is the supervision directive or more consultative? What are the skills and experience of the person(s) providing the supervision? How are decisions made in the practice? Do you have input? Are there one or two people who make the decisions, or is it more consensus driven? What financial information is shared with the professional staff?

Restrictive Covenants (better known an Non-Compete Agreements): It is not uncommon for employers to want to protect their practice from the posibility of hiring someone who stays a year, builds a caseload, is exposed to how a successful practice operates, meets the referral sources and then leaves to go it on their own. Employers may ask you to sign a contract that in some way tries to restrict your ability to take the key asset of the practice (their business) with you, should you decide to leave. You can check with your attorney about these and other contractual clauses. Generally, it is thought that while the employer can require some restrictions, these restrictions need to be reasonable and should not prevent you from earning a living if you decide to part ways. Be careful and make sure you read the fine print about this and other conditions around the eventual termination of your employment. There are some jurisdictions (e.g., New Jersey) where it is illegal for mental health professionals to either offer or enter into such an agreement and others where such agreements are very narrowly focused. Once again, consult with your attorney on this issue

Signing the Agreement

Congratulations. You have found a practice that wants you to join them and you want to join them as well. There are two sets of professionals that need to review the contract prior to you signing on the dotted line. Contracts tend to be written in a way that primarily protects the practice. After all they generate the contract and why wouldn’t they want to place a primary emphasis on protecting themselves and their business interests?

First, and foremost, the agreement needs to be reviewed by a senior-level private practioner. There is no reason to believe that someone who has never been in private practice previously will understand the ramifications of what is written in the contract. This is not legal advice but rather the reviewer may be able to generate a list of questions to ask that had not been previously considered or point out “red flags” TPI provides this service if you cannot find a senior-level person in your area.

Second, the contract should be reviewed by an attorney who practices health care law. Ideally, they will be familiar with the practice of mental health professionals. The attorney may be especially familiar with issues related to restrictive covenants, ownership of clinical records, responsibilities of each party if the agreement is terminated.

Yes, these services do cost money. However, they are but a small investment if they protect you from a larger loss or restriction professional practice opportunities at a later date. In addition, the costs are tax deductible as a cost of doing business. The old adage is true: “Some times you have to spend money to make money” or to protect your assets.

Some Concluding thoughts:

The search for a practice to join and the interview process does not have to be one based on fear and insecurity. It is a process of each side assessing their perceptions of fit. Understanding that there is a lack of fit is as important as being clear that the practice is absolutely one in which you want to work. Being honest about what you need and what you have to offer is probably the safest way to try to assure for a good fit.

If indeed you think you have found the fit, don't hesitate to say so. It may be true that there is another candidate who is being highly considered, but who the employer is concerned will be difficult to negotiate with or may not join them. Hearing that you will accept an offer if made, can go a long way to actually securing the offer. However, it is important to not take this lightly. Many communities are small and the networks between practices are tight. If you lose credibility with that employer, you don't know how and when that might hurt your reputation elsewhere over the course of your career.

So, hopefully this practice guide has given you a better sense of the search and interview process and how to prepare for it without undue anxiety. In short, be prepared, be honest and make sure that while they are interviewing you, you are interviewing them.


Questions To Consider Asking When Joining A Group Practice

From: Walfish, S. & Barnett, J. (2008) Financial success in mental he alth practice. Washington D.C.: American Psychological Association.

  • What are the values of the practice?
  • What are the vehicles of criticism for what takes places in the practice?
  • How does the practice fit into the larger community? What is it’s reputation?
  • What will the benefit be to me in joining the practice?
  • What will be the benefit be to the practice by my joining?
  • What is the history or evolution of the practice? What phases has it gone through? Have their periods of growth? Periods of constriction?
  • What is it about me compared to other people that have been interviewed which makes me an attractive applicant to join the practice?
  • Has anyone previously left the practice? If so, what were the circumstances?
  • If the group is multidisciplinary is there a power difference amongst the different disciplines?
  • How do practice associates relate to practice partners/owners?
  • What is the timetable for me joining the practice?
  • How quickly could I expect to develop a full-time practice?
  • What is the referral base of the practice? Are there specific contracts to the practice that provide clients?
  • How will other people in the practice react to my joining? Is there competition for referrals? What has happened historically when a new member has joined the practice?
  • What happens if there are perceived ethical conflicts within the practice?
  • How are internal conflicts handled in the practice?
  • What is the near-term and long-term vision for the practice? Do practice associates share in the development of this vision or is this solely decided by the practice owners/partners?
  • What is the process for adding new members of the practice? What avenues are there for professional growth within the practice?
  • How are resources spent in the practice? How are decisions made about spending resources? What happens when resources are tight?
  • Are the fees set by the practice or do I set my own fees?
  • What are the hours available to see clients? What type, if any, of support staff is available after hours (e.g., weekends, evenings)?
  • What type of emergency coverage is available for when I am not available or I am out of town?
  • What resources are provided to me as part of my contribution to overhead? Does this include receptionist support, secretarial, office supplies, telephone, long distance costs related practice activities, office supplies, photocopying, psychological tests, etc.?
  • What are the billing and collection practices of the practice? What happens if someone does not pay their bill? Are insurance benefits verified by support staff?
  • What is the success rate of collecting fees charged?
  • Is everyone in the practice a provider for the same insurance companies? Do I have to take insurance? Can I be selective in which insurance I take?
  • What happens to my practice and place in the practice if I go on maternity or paternity leave?
  • How much of my practice should I be expected to generate and how much can help can I expect from the practice?
  • Is there a minimal amount of practice hours that is expected of me?
  • Is there a maximum number of hours that I may be allowed to practice?
  • Are there limitations in how I practice? The type of work I do or clients seen?
  • How does income generated outside of direct clinical practice within the practice fit into the equation?
  • Are there limitations as to where else the clinician can also practice?
  • What is the financial solvency of the practice? Have they ever had difficulty meeting their financial obligations?
  • How are clinicians paid? Does the practice collect all monies and then pay the clinician once or twice per month or does the clinician collect all monies and then pay the practice once per month?
  • Will I have my own office or do I have to share an office with others? Will I have to “float” to use offices that are available?
  • If I have my own office will I have to furnish the office or will it be furnished for me? If furnished for me do I have a say in what it looks like?
  • How does an associate become a partner in the practice? How long does it typically take to become a partner and what are the expectations of associates and partners?