Congratulations on graduating, CF-SLP! Welcome to the CFY job search, the first gauntlet of your new career. The good news is, getting that CFY job is something you only have to do once.

...well, hopefully once. Unfortunately, there are a lot of people out there who take CFY jobs that turn out to be miserable, to the point that they decide to quit and find another CFY job to finish out the fellowship period. You know how much the CFY hunt sucks, so it really says something when a person decides to jump ship and put themselves through the wringer again.

New clinicians often struggle to determine if a job offer is reasonable, and if an employer seems decent. In many cases, the CFY is your first experience ever with a professional-class job, where the expectations and standards are different from positions like retail, hospitality service, or working at summer camps. 

I will say this as politely and professionally as I can: a lot of SLP employers are crap. The quality of clinical service delivery may be outstanding, the practice may be decades-old and have multiple locations, and the clients may report high satisfaction. Sadly, when it comes to what is good for the practice, what is good for the clients, and what is good for the clinicians...the clinicians are prioritized dead last (if even considered at all). Clinics can get away with this because there is a constant supply of naive, eager, and debt-ridden CFs who graduate every year that can be reliably recruited and discarded as needed.

Lest it seem like I am mincing words about our industry, I should also clarify: a lot of these crap SLP employers are not large corporations, but private practices founded and run by clinicians. To be fair, most SLP founders are far more expert in the clinical realm than they are in the business realm. Poor business practices that exploit or harm clinical staff often stem from lack of awareness, not greed or malice. 

So, in the spirit of raising awareness -- for job-seekers who don’t understand what they’re looking for, and for employers who don’t know what they might be missing -- here are some woefully common unethical practices in SLP employment.

Unpaid Labor

This is both unethical and very, very illegal.

In both the private practice and medical settings, SLPs are frequently unpaid for any work that does not involve direct therapy with a client. This includes tasks like coordinating care with other clinicians, writing documentation, communicating with family members, attending staff meetings, attending staff trainings, preparing for therapy, participating in in-services, time getting to and fro the session (whether walking between patient rooms or driving between in-home visits), and more.

At the time that I quit my SNF job, our productivity requirement was 92%. On a day where I rendered 6 hours of billable hours (somewhere between 8-12 patients), that allows for 28.8 minutes to do all of the above tasks. I was also supposed to screen all new patients every day, which is a non-billable task that averaged about 10-15 minutes per patient. We typically had 2-8 new admits per day.

Our rehab team of physical therapists, occupational therapists, and SLPs handled this by working off-the-clock, doing things like documentation, care coordination, and family communication. I would estimate that each person on our roughly 20-person team spent between 2-10 hours per week working off the clock.

In private practice, it is common for employers to use a per-visit reimbursement model. Employees are paid hourly based on how many clients they see. [Note that this is problematic for W2 employees; this may be fine for 1099 contractors.] However, employees may also be asked to keep the materials room organized, attend staff meetings, manage scheduling, and travel. Many private practices conveniently neglect to count these non-billable hours when calculating payroll. 

SLPs are working even when we aren’t actively billing. Employers who refuse to compensate employees for working hours are breaking the law.

Don’t take a job that is only going to pay you for a portion of your time. If you are in a job where you are only being paid for a portion of your time, you can report your employer to get your pay structure adjusted and potentially your wages back.

We’re not perfect, but here’s how we handle this: we compensate our employees hourly at 2x their billed hours. This accounts for a typical amount of assigned non-billable duties. If an employee is asked to take time to complete a task or meeting that goes beyond those typical assigned non-billable duties, they track time and are compensated accordingly. As a practice, this is financially sustainable because we use a lower hourly rate relative to jobs that demand 80%+ productivity. With the 2x multiplier, overall compensation balances out. 

Prioritizing client preferences over employee well-being

Years ago, I worked in the office of a large private practice. I remember a conversation where I asked the practice manager how they determine caseload sizes and schedules for the clinical staff. I don’t remember the basic formula that he described, but I distinctly remember this part:

“...and we generally try not to have our SLPs work on Saturdays, but sometimes it can’t be avoided. So sometimes they might see a client or two on Saturdays.”

This was a practice where the office dictated the caseload size and schedule for the SLPs, in terms of hours worked. Staff had no say in when and where they worked. This was an incredibly BS response. If you were really “trying” to give your employees two full weekend days off, you would just not allow clients to schedule on Saturdays.

Another SLP I met told me about a large practice she worked at briefly, in another part of the country. A family asked for their child to be transferred to a different SLP. The child’s SLP was a Black man and the parent directly stated they did not feel comfortable having their young child receive therapy from a Black male clinician. The practice obliged in order to keep the client happy and comfortable, and reassigned the child to a female clinician of a different race.

During COVID, I have been especially alarmed at the number of friends and colleagues who are providing in-home therapy at the behest of their employer, because “that’s what the client wants”. If it’s a situation where a client doesn’t have Internet or computer access and teletherapy is not an option, this is tricky. We have professional ethics regarding continuity of care and client abandonment, so something needs to be provided. Outside of that scenario, though, private employers who require employees to expose themselves to health risks because a client “prefers” a certain therapy medium are sending a loud, clear signal about how much they care about their employees. 

Because we are trained to put the welfare of our clients above all else, we have normalized sacrificing not only our comfort, but actual well-being, as we go about our jobs. (ASHA even reinforced this last year, publishing an article recommending that SLPs and AuDs use “crying in your car” as a strategy for dealing with unsafe or unethical work environments. ASHA recanted the suggestion after much backlash.) This client prioritization value is frequently abused by employers who demand that their clinical staff subject themselves to abusive or aggressive client behaviors (by which I mean parents and sound-minded adults, not children or those with diagnosed disabilities), unsafe work environments, or schedule demands that assume the SLP has no personal or family life. 

We’re not perfect, but here’s how we handle this: All employees are given full autonomy over their schedules, and may decline client assignments for any reason. We prioritize clinician comfort, safety, and preferences over client preference. In cases of competing needs between a client and clinician, we have a careful conversation to see if we can find a workable common ground. For clients who can’t or won’t work within our clinicians’ self-determined workflows, we refer out to practices that are a better fit.

Designating clinicians as 1099s to avoid taxes and liabilities

This is an issue with legal repercussions for the employer, and one that can be tricky to navigate. Many SLPs enjoy contracting with a private practice (or three!) as a 1099, seeing 1-2 clients a week on top of a regular school or medical job. This is a common, great, legal, ethical arrangement.

While what defines a 1099 contractor vs W2 employee can be a little subjective, the IRS has guidelines, some of which are quite basic. I know of private practices who employ SLPs that see 30 clients a week at that practice, which is their sole source of income...and the clinician is classed as a 1099 contractor. 

Private practices, particularly small private practices with owners who don’t have strong business skills and knowledge, are prone to these serious misclassification errors due more to naivete than an intent to exploit. Classifying workers as 1099s absolves the employer of any obligation towards stable employment and benefits such as sick time and PTO. Small practices may feel overwhelmed at the thought of setting up payroll infrastructure and reporting for W2 employees, and so “prefer” to keep everyone as 1099, even though that is illegal. This is harmful to the clinician who seeks a stable, steady job, because 1099 has no guarantee of hours worked (income), and the worker is responsible for paying significantly more income tax. 

Again, 1099 vs W2 is a tricky matter since there are lots of good reasons to adopt 1099 employment and the certain benefits it carries. If an employer is offering you 1099 status where you will be working significant hours and they control your schedule and assignments, that’s a red flag that they are misclassifying you (meaning you are not getting the benefits of being a 1099, but are getting all the downsides including sending a large percentage of your pay to income taxes, much more so than as a W2).

We’re not perfect, but here’s how we handle this: Clinicians who see 5 or fewer clients per week, on average, are classed as 1099 contractors. Clinicians who see between 6-10 clients per week are given the option to be classed as a 1099 contractor or W2 employee, based on their personal preference. Clinicians who see 10+ clients per week are converted to W2 employees.

Summary

A good employer is one that adheres to employment law, sets reasonable and transparent expectations for job duties, and has policies that prioritize the well-being and security of their employees. 

COVID is a buyer’s market. Newly-minted CFs may find it even harder to land a job in 2020, as medical positions have been cut and school-based SLPs are jumping ship due to concerns about personal safety. This makes it easy for employers to take advantage of job seekers. 

Employment law stands, regardless of supply and demand. Advocating for yourself, or better yet, with a group of coworkers, can bring about change (especially for employers who are well-intended and simply unaware).

Additional Resources

Askamanager.org

Employee Rights from the EEOC

Employment issues community on Reddit