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Searching for the First Job: A Perspective

Soon our current third-year residents and OB fellows will graduate, and most will start their first job as an attending. As family medicine physicians, we provide comprehensive care for our patients, at any time or age in life. I think this drives many of us to envision a career spent in one place, right from the start. The data, however, show a different story. While not specific to family medicine, it is estimated that 40-70% of physicians change jobs in the first five years of their first attending position.1 Why does this happen, and how can this be prevented?

Numerous factors play into this statistic. The job may not be what you thought. Perhaps the location does not work out. Maybe family changes prompt a move closer to (or further away from) relatives. Consider marriages, divorces, finances, career advancement … the list goes on. While not specific to job changes in the first 5 years, surveys have shown that the top reasons for physicians leaving their jobs (in general order) include:

Natalie Krier, MD, IBCLC
  • Burnout, for many reasons, including feeling undervalued, lack of support, poor work-life balance, excessive administrative tasks
  • Moral injury, including lack of autonomy from both administration and insurance companies
  • Cost of living/inflation/financial instability
  • Career advancement and benefits
  • Family reasons2,3

If I looked at these statistics at the end of my residency, I would indeed have asked, “How can this be prevented?” Now that I’m a few years into my attending career, however, I think the focus should be shifted to, “How can residents and fellows best plan for this?”

You don’t know what you don’t know.

Residency (and fellowship) is an intense period of training across many areas of medicine. Most attending jobs are nothing like residency. A typical family medicine resident transitions from staggering a few half days of clinic among long 12-hour hospital shifts to a nearly 100% outpatient practice. With that first contract, a physician is committing to a work schedule they have no experience with. A resident who dreaded the 14-day stretch of 12-hour inpatient shifts may find being a hospitalist quite enjoyable when it’s done for only 3 days at a time, or 7 days on followed by 7-14 days off. Conversely, a resident who managed well doing 2-3 half days of clinic per week might find being in clinic all day every day of the week absolutely draining (not to mention all the time spent at home charting). The average workday of an attending is drastically different than that of a resident, and adjustment to that change is difficult to predict. The workflow you think you want may not work out. That is OK. Be open to that possibility.

Financial reasons

I cannot stress the importance of this topic enough. While financial problems may be the driving factor in needing to change jobs, DO NOT let it hold you down when leaving a job is needed. Significant pitfalls in this area include:

  • Attractive recruitment packages (sign-on bonus, relocation stipend, residency stipend, loan repayment, etc.)
  • Immediately purchasing the “doctor house” or “forever home”
  • Escalating from “living like a resident” to an “attending lifestyle” too quickly

Sign-on bonuses are attractive and flashy. While a higher recruitment package may be a sign of appreciation and paying physicians what they are worth, they also tend to be higher in places where it is harder to recruit and retain physicians. Are attractive recruitment packages always something to avoid? Definitely not. For example, recruitment packages tend to increase the more rural the practice is, because rural practice is not for everyone. But for someone who desires to practice in a rural area? Take advantage of those benefits!

Transitioning from a resident salary to an attending salary, especially one with a hefty sign-on bonus, is significant. The downfall for many is poor financial planning. This can cripple future job options. For example: you take a job with a $150,000 sign-on bonus that is forgivable after five years of employment. If you leave prior to the five-year mark, you must repay that portion, likely with interest. After two years, it’s clear the position is not a good fit, the family is not happy, and change needs to happen. You plan to leave after 2.5 years, owing $75,000 (plus interest) on a sign-on bonus you maybe only received $100,000 of after taxes. Can you afford to leave that job? What if you need to factor in the need to sell a large house that will likely sit on the market for an extended period of time and sell below what you paid? And what if after upgrading your lifestyle you were comfortable living on the two-year guaranteed salary and now find you don’t have the budget to keep up with your lifestyle because on year three of employment your salary changes to production and you are making less than before?

The lesson is not to refuse sign-on bonuses, rent a tiny apartment, and live like a resident indefinitely. But recognize there are areas to mitigate risk. Pay off debt and build up an emergency fund. Negotiate for a smaller sign-on bonus with subsequent retention bonuses. Rent for the first year or buy a house that you could weather selling in less than five years if needed. Increase your lifestyle spending in increments, always keeping in mind future shifts in payment structure.

Family reasons

Another unpredictable cause for job change is family reasons. New attendings are, by definition, early career physicians. Many are in the early family phase of life, as well. I had my first child two weeks after I graduated from residency. This means I accepted my first attending job: 1) never having worked while having a family with a baby; 2) not thinking of school systems and extracurricular/family activities; 3) never having lived far from family with a family and baby of my own.

While you can plan for some of this, a lot of it falls under the “you don’t know what you don’t know” category. Be open to accepting there are many unpredictable factors that may lead to a job change.

I hope all the upcoming graduates find a career home that is enriching and rewarding, where you can use the skills you’ve learned to provide comprehensive care to all patients in any setting. But I also hope you can accept and be prepared if changes need to be made.

  1. (2017, August 9). Higher Job Turnover In Medicine Than Expected. InvestingDoc. Retrieved January 19, 2024, from
  2. Physician on Fire. “Top 5 Reasons Why Physicians are Leaving their Jobs in 2023: Based on a Survey of 1639 Doctors.” Physician on FIRE, 19 September 2023, Accessed 30 January 2024.
  3. EntreMD. “5 of The Top Reasons That Doctors Quit Their Jobs.” The EntreMD, 28 October 2022, Accessed 30 January 2024.

About the Author Heading link

Dr. Natalie Krier is a Clinical Assistant Professor in the Department of Family and Community Medicine.