Graduating fellows....any advantage of going into PP instead of hospital employee?

[DrSpine]

This is well summarized. The only caveat I would say is when you mention hospital employees work like dogs to chase wrvus. That implies PP docs don’t work all that hard, or take tons of free vacation without a worry. Which isn’t true in my experience. EVERYONE works hard. And income is proportional to that in any setting

PP people work probably harder than hospital employees. The difference is, in PP your hard work generally pays off a lot better esp if you own it. The hospital RVU system plays a cat and mouse game with you. You are just constantly worked to the ground to meet this “base pay” or close to what you were given the first two years. After the initial base, the Hospital RVu system is a scam. Putting in that same work in PP yields you a lot more money.

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[DrSpine]

Basically, every successful doc in the first 10 plus years of their practice has to see patients to make money. It is basically a 1:1 deal be it in units or cash, it all becomes cash in the end.

as you get further in practice medical related but not direct patient care income potential for private practice is much higher. Real estate, employed physicians, etc.

This.

 

[paindoc007]

PP people work probably harder than hospital employees. The difference is, in PP your hard work generally pays off a lot better esp if you own it. The hospital RVU system plays a cat and mouse game with you. You are just constantly worked to the ground to meet this “base pay” or close to what you were given the first two years. After the initial base, the Hospital RVu system is a scam. Putting in that same work in PP yields you a lot more money.

Not all hospitals contracts work in the way you’re describing of “work the doc in the ground. Oh that’s just to meet a crappy base. Then work 2x that to make a little extra”

Mine certainly doesn’t. I make an income relative to what I do. Wrvu is just a way of quantifying it. Wrvu * $/wrvu = income. Simple as that.

 

[Laryngospasm]

Yes hospital docs at least know what we are getting paid for and don’t get the pie in the sky partnership pulled out from under us. I go in.. do as little work as needed and go home and don’t do call, nights, weekends or administrative stuff. My last PP job did not pay health or tail and if you got sued you were on your own and had to pay for representation. And let me tell you during corona it was nice to have a guarantee.. I would have starved at my old pp job where it was eat what you kill and the state closed down non emergent clinics so they had to do phone visits and no procedures.

 

[DrSpine]

Yes hospital docs at least know what we are getting paid for and don’t get the pie in the sky partnership pulled out from under us. I go in.. do as little work as needed and go home and don’t do call, nights, weekends or administrative stuff. My last PP job did not pay health or tail and if you got sued you were on your own and had to pay for representation. And let me tell you during corona it was nice to have a guarantee.. I would have starved at my old pp job where it was eat what you kill and the state closed down non emergent clinics so they had to do phone visits and no procedures.

Counter argument to this / devil’s advocate here. This is indeed true, you know what you are getting paid for in terms of wRVU. And yes, things have worked out for you. However, at any moment, when not owning a practice, hospital administration can change, and as we have seen countless times, contract points may change or upon the new annual year, changes will be made to contract with compensation, etc. This also applies to PP employment, one is not immune from changes. This is why I am a large advocate for ownership. The only way one can be in control of their own destiny.
But to go back to OP’s question, there are pros and cons to both. We are all starting the benefits and disadvantages of each. You hold a point with some of the positive aspects of hospital employment. And yes, too many PP have lied and screwed over young post fellow grads.

 

[DrMDAware]

At the end of the day; get your experience, then open up your own gig.

Good points. What else would you get besides experience in order to hit the ground running (ie contracts, office space located, equipment, online reviews, templates, staff, loans)?

Basically, every successful doc in the first 10 plus years of their practice has to see patients to make money. It is basically a 1:1 deal be it in units or cash, it all becomes cash in the end.

as you get further in practice medical related but not direct patient care income potential for private practice is much higher. Real estate, employed physicians, etc.

Very well summarized. After 10 years there are ways to break the time = money mindset.

Yes hospital docs at least know what we are getting paid for and don’t get the pie in the sky partnership pulled out from under us. I go in.. do as little work as needed and go home and don’t do call, nights, weekends or administrative stuff. My last PP job did not pay health or tail and if you got sued you were on your own and had to pay for representation. And let me tell you during corona it was nice to have a guarantee.. I would have starved at my old pp job where it was eat what you kill and the state closed down non emergent clinics so they had to do phone visits and no procedures.

Yes x1000. C19 has definitely altered things. The guaranteed money looks even sweeter.

Counter argument to this / devil’s advocate here. This is indeed true, you know what you are getting paid for in terms of wRVU. And yes, things have worked out for you. However, at any moment, when not owning a practice, hospital administration can change, and as we have seen countless times, contract points may change or upon the new annual year, changes will be made to contract with compensation, etc. This also applies to PP employment, one is not immune from changes. This is why I am a large advocate for ownership. The only way one can be in control of their own destiny.
But to go back to OP’s question, there are pros and cons to both. We are all starting the benefits and disadvantages of each. You hold a point with some of the positive aspects of hospital employment. And yes, too many PP have lied and screwed over young post fellow grads.

So, the recommended path is to start out with guaranteed money from a hospital and try to do as little scut work and admin games as possible and then in 2-3 years transition to your own gig and control your own destiny?

 

[DrSpine]

Good points. What else would you get besides experience in order to hit the ground running (ie contracts, office space located, equipment, online reviews, templates, staff, loans)?


Very well summarized. After 10 years there are ways to break the time = money mindset.

Yes x1000. C19 has definitely altered things. The guaranteed money looks even sweeter.

So, the recommended path is to start out with guaranteed money from a hospital and try to do as little scut work and admin games as possible and then in 2-3 years transition to your own gig and control your own destiny?

I mean pretty much this is what I am advocating. It’s ultimately everyone’s decision but I’d rather bring in less, yet be my own boss / owner than the other way around. It’s more work, but it’s far more rewarding, and you are building equity/ownership into something. Seems like a no brainer. Job security will forever be better than being held by golden cuffs or strings from the powers that be above. Just because a job is great now doesn’t mean it will continue to be. You don’t want to be that guy who is suddenly stuck with a miserable job but too old to leave or kids in school. Just my two cents. But some will be employees and some will be small business owners, just the way the natural order of the world works. In the meantime, yes, given the circumstances I think it’s best to be a hospital employee to start out with versus PP employee unless your tail is covered.

 

[Laryngospasm]

And for those of you who don’t know tails can be from 40-100k. And you have to pay it all upfront. They don’t offer a payment plan at least that was my experience. So you get a job you don’t like work there a couple years and they screw you financially and then when you leave write that fat check.. it stings trust me.

 

[Sooshi]

After interviewing at a number of PP places, I'm looking to go back to my old hospital. It's a paycut compared to boondock PP, but I get stability, a much nicer schedule, living in a major metro area, teaching, CME and research time, the ability to hang out with residents/my old attendings, and I don't have to drum up business or answer calls after hours.

Both have definite pros and cons. I'll never make enough to buy a new boat every time the old one gets wet. That being said, I realized that for me there's more to life than just making an assload of money at the expense of the rest of my life. Also, I grew up in the Soviet Union, so I'm basically bulletproof when it comes to the bureaucracy.

 

[drusso]

After interviewing at a number of PP places, I'm looking to go back to my old hospital. It's a paycut compared to boondock PP, but I get stability, a much nicer schedule, living in a major metro area, teaching, CME and research time, the ability to hang out with residents/my old attendings, and I don't have to drum up business or answer calls after hours.

Both have definite pros and cons. I'll never make enough to buy a new boat every time the old one gets wet. That being said, I realized that for me there's more to life than just making an assload of money at the expense of the rest of my life. Also, I grew up in the Soviet Union, so I'm basically bulletproof when it comes to the bureaucracy.

Please share your observations about health care bureaucracy in the USSR.

 

[Sooshi]

Please share your observations about health care bureaucracy in the USSR.

You know how in academic medicine, there's often a committee for everything, people keep having pointless meetings, talking about goals, coming up with acronyms and creating endless training modules, without ever accomplishing anything? Imagine that, x10, but in every area of life, with corruption and pilfering of resources on top of it.

 

[Ducttape]

your argument is from someone who clearly favors PP, not only in what you are saying, but even looking at how you have typed the pros and cons.

first, your cons apply not only to hospital employed but to practice employed physicians. by PP - you seem to be specifically talking about individual ownership. the cons you list are cons that will occur when someone else - ie physician employer/owners - controls the books.

you run the hamster wheel for them, and they will fire you if you are not producing and have no obligation to share in any of your work outside of what you negotiate. now of course there is the possibility of becoming an owner yourself in that situation.

in all these cases - hospital employed vs employer model, whether it is a group or physician - the end dynamic is about relationships and relationship building. each administration you go through as an employed physician has different dynamics and if one cannot tolerate that, then definitely, solo practice is the way to go.

assuming you have the chops to be a businessperson.


in addition to the hospital pros, please consider:
1. location, location, location. some people have to take hospital employed positions if the market is saturated due to family requesting certain locations.
2. likewise, competition - if the market is saturated, one cannot reasonably initially - or possibly ever - open a private practice.

in PP cons:
1. i would suspect you have to be a businessperson first and a physician second for your own private practice. in similar vein, see point 3 below
2. you still have to be a good judge of character to be in private practice - with regards to hiring staff, keeping them happy, hiring partners, etc. a lot more flexibility but a lot more responsibility on the owner.
3. while there is greater risk of being fired as an employed physician, there is similarly a greater chance of the practice failing - and it would be all on the physician.
4. PP doctors must be more invested in the non-medical aspect of their practice - who shovels snow, upkeeps property, mows lawn, works on signage, does advertising, markets to referral base, does payroll, etc.
5. in PP, you have to put up a lot of your own capital, and take home pain is a lot lower initially but seems to have much greater potential.

I'm old. I'm willing to trade all the hassles of running a business for going home a little earlier to spend time with the kids.

This is my personal answer:

As a NEW fellow getting out, I would advocate you eventually owning your own practice or getting partnership into a practice (latter is harder to do as it requires trust and assuming they'll give you true partnership). With that being said, it is obvious that you cannot open something immediately after training given level of debt and inexperience.

So, you will need most likely employment for 2-3 years.

 

[drusso]

You know how in academic medicine, there's often a committee for everything, people keep having pointless meetings, talking about goals, coming up with acronyms and creating endless training modules, without ever accomplishing anything? Imagine that, x10, but in every area of life, with corruption and pilfering of resources on top of it.

Please contribute more to our discussions here on a variety of topics. Your lived experience in a collectivist utopia and help others see the limitations of that kind of thinking. There are people on this forum that want to re-create strong central control/ Big Government in our profession.

 

[Nodolor]

Please contribute more to our discussions here on a variety of topics. Your lived experience in a collectivist utopia and help others see the limitations of that kind of thinking. There are people on this forum that want to re-create strong central control/ Big Government in our profession.

Ya Keep Government out of my Medicare!

 

[drusso]

your argument is from someone who clearly favors PP, not only in what you are saying, but even looking at how you have typed the pros and cons.

first, your cons apply not only to hospital employed but to practice employed physicians. by PP - you seem to be specifically talking about individual ownership. the cons you list are cons that will occur when someone else - ie physician employer/owners - controls the books.

you run the hamster wheel for them, and they will fire you if you are not producing and have no obligation to share in any of your work outside of what you negotiate. now of course there is the possibility of becoming an owner yourself in that situation.

in all these cases - hospital employed vs employer model, whether it is a group or physician - the end dynamic is about relationships and relationship building. each administration you go through as an employed physician has different dynamics and if one cannot tolerate that, then definitely, solo practice is the way to go.

assuming you have the chops to be a businessperson.


in addition to the hospital pros, please consider:
1. location, location, location. some people have to take hospital employed positions if the market is saturated due to family requesting certain locations.
2. likewise, competition - if the market is saturated, one cannot reasonably initially - or possibly ever - open a private practice.

in PP cons:
1. i would suspect you have to be a businessperson first and a physician second for your own private practice. in similar vein, see point 3 below
2. you still have to be a good judge of character to be in private practice - with regards to hiring staff, keeping them happy, hiring partners, etc. a lot more flexibility but a lot more responsibility on the owner.
3. while there is greater risk of being fired as an employed physician, there is similarly a greater chance of the practice failing - and it would be all on the physician.
4. PP doctors must be more invested in the non-medical aspect of their practice - who shovels snow, upkeeps property, mows lawn, works on signage, does advertising, markets to referral base, does payroll, etc.
5. in PP, you have to put up a lot of your own capital, and take home pain is a lot lower initially but seems to have much greater potential.

I'm old. I'm willing to trade all the hassles of running a business for going home a little earlier to spend time with the kids.

Ah, the story of my life...

 

[kstarm]

There are so many different jobs and how they work. You can have a great job or a crappy job in either. Figure out what is most important to you. For many money is the most important, for others autonomy, others it may be mentorship at least starting out, or the ability to teach. Be honest with yourself about what you want to do. Most of the doom and gloom on here about hospital based (admin, inpatient, etc) has not been my experience. I guess that could change but 7 years in and I have significant autonomy, make my schedule, practice how I want and if I want to make more money I see more people. That is essentially it. I agree the ceiling is higher in PP if you own things. As above, I am sure there are terrible hospital based jobs too. I am curious about all those on the board stating the freedom they experience in PP if they are owners? IT seems that those that join PP as non-owners have pretty rigid guidelines they are asked to do to feed the machine. At least in my area, the owners stay the same, and the other docs tend to rotate around or strike off on their own.

 

[BobBarker]

Agreed. I make my own schedule, they let me dabble with a private practice project out of town, etc. basically get left alone.

 

[SommeRiver]

Employed MD in a large ortho group, and I have it made in many ways...Don't ever believe PP = Partnership or find a new job.

You may not want to be a partner TBH.

I get 95% internal referrals, so drug seekers are extremely rare in my clinic. I have some local ortho surgeons who send me all their spine pts, but usually I don't see new pts to the clinic.

It is backwards - To get to me you have go through the spine or joint surgeons. Understand that protects me in many ways though...

I'm given salary, production bonuses, and I have ASC shares in one of our two ASCs (I didn't have to buy them either).

Never be a partner here - Do I need to be a partner?

Will I ever get a vote on buying a new EMR or hiring other doctors or anything at all? No.

I don't get profit sharing.

As an employed doctor in this group, I am the purest definition of being left alone and in 4 yrs I've never had a single person say one thing to me about how I practice, who I see, what I Rx, who I fire...

I had our ASC director say I couldn't do PNS bc it doesn't pay enough (oh darn...).

...but I don't have a vote at the table.

Point being, sometimes going into PP doesn't result in partnership, but you may not ever want that, nor need it.

You can make a lot with minimal life impact in PP without owning the practice, and you can do it without being oppressed by hospital admin or people looking over your shoulder.

 

[Ligament]

You guys are not considering time investment. In PP, if you are a partner or owner, you are seeing patients during the day, and doing business at night. Talking to your SEO guy, deciding how to redesign the website. Do you want to spend $2000 on updating the clinic bathroom? Let's have a meeting about a new EMR. Do you want to wast X $ on this EMR or X $ on that EMR, and which one sucks less. Signing a contract for the business? How much is the lawyer going to cost this time? What autoclave should you buy, and do you really need to get rid of your old one? Is it really broken? It's never ending.

 

[drusso]

Employed MD in a large ortho group, and I have it made in many ways...Don't ever believe PP = Partnership or find a new job.

You may not want to be a partner TBH.

I get 95% internal referrals, so drug seekers are extremely rare in my clinic. I have some local ortho surgeons who send me all their spine pts, but usually I don't see new pts to the clinic.

It is backwards - To get to me you have go through the spine or joint surgeons. Understand that protects me in many ways though...

I'm given salary, production bonuses, and I have ASC shares in one of our two ASCs (I didn't have to buy them either).

Never be a partner here - Do I need to be a partner?

Will I ever get a vote on buying a new EMR or hiring other doctors or anything at all? No.

I don't get profit sharing.

As an employed doctor in this group, I am the purest definition of being left alone and in 4 yrs I've never had a single person say one thing to me about how I practice, who I see, what I Rx, who I fire...

I had our ASC director say I couldn't do PNS bc it doesn't pay enough (oh darn...).

...but I don't have a vote at the table.

Point being, sometimes going into PP doesn't result in partnership, but you may not ever want that, nor need it.

You can make a lot with minimal life impact in PP without owning the practice, and you can do it without being oppressed by hospital admin or people looking over your shoulder.

Are you saying new grads shouldn't want to control their own destinies? You've either got a seat at the table or you're on the menu.

 

[lobelsteve]

Are you saying new grads shouldn't want to control their own destinies? You've either got a seat at the table or you're on the menu.

So if you don’t own it you aren’t in control? Condescending.
I work 38 hrs per week. I dont work nights, weekends. I pay no bills. I have no overhead. I have my LLC if I want baller money. But I’d rather spend time with kids, my garage, and exercise. Only so many hours in a day. I’m having too much fun and do not care to be stressed every hour of every day.

 

[Agast]

Find the job that lets you be a good doctor. Most of the folks I knew who left their first job, felt like they were being pressured to do shady things. No amount of money or packages will make you feel good about that at the end of the day. You won’t know how bad it is until you live through it. Just don’t buy a house right away, rent until you’re sure you want to stay put.

 

[au bon pain]

It's interesting that nobody has brought up a growing cancer in the pain market: private equity groups.

Many of the docs I've met who work for these groups seem like good folks, but the outlook for a new doc joining them is...grim.

 

[drusso]

So if you don’t own it you aren’t in control? Condescending.
I work 38 hrs per week. I dont work nights, weekends. I pay no bills. I have no overhead. I have my LLC if I want baller money. But I’d rather spend time with kids, my garage, and exercise. Only so many hours in a day. I’m having too much fun and do not care to be stressed every hour of every day.

Well, technically, yes. I worry that Millennial doctors and others have been brainwashed into being cogs in a health care machine. Remember, just a little more than a generation ago DOCTORS ran hospitals and hired management to oversee day-to-day operations.

But, I get what you're saying. I'm dong a Saturday clinic today to get caught up procedures that had to be rescheduled due to weather and other events. I do it not because I care, but because I'm the boss. The buck stops here. I just can't make it someone else's problem.

 

[SommeRiver]

Are you saying new grads shouldn't want to control their own destinies? You've either got a seat at the table or you're on the menu.

EVERYONE is on the menu - You may own your own practice; perhaps you're one of three or four guys and your vote matters...That is not the case in all partnerships.

Partner does not mean you control your own destiny - It depends on the size of the practice.

I have remarked for years one must be sociopathic to be a neurosurgeon or spine surgeon, with general orthopedic surgery being less sociopathic but it is a requirement nonetheless (arthroscopy is soooooo great). Spine surgery is unnecessary in what percentage of cases? I have no hard number, but let's agree it's a huge percentage (probably over half IMO). You know you're not fixing that patient; you know they're going to hurt afterwards; you know you're not going to have to deal with the patient afterwards - Who cares? You'll drive home in a BMW M8...Who GAF? Not your problem...Cut them and send them off...

That is sociopathic behavior in the exam room and operating room...But what about sociopathic behavior in the board room?

In large ortho groups, sociopathic behavior extends to the board room - They cannibalize one another; It is ultra competitive and gross in my practice.

My personality is not conducive to partnership - There have been instances in board meetings where dudes have gotten face-to-face and yelled at each other and there are no consequences for it. Your avg doctor is a dork who's never worked a regular job or been in a fight.

There is no way I benefit from being a partner if I weigh everything.

1. Make more money? Yes, I would make more...So what? What exactly does that mean? I make a lot now and it all just sits in my account. I don't like expensive cars. Money is irrelevant once you're around 85-100k after taxes, and I'm way over that. So, who cares? How much more are we talking? Pretend I make another 100k...Okay, my lifestyle changes not at all. Maybe a large hospital system or Private Equity buys the practice and I make a lump sum. Cool, but that just changes the numbers on the computer screen at Wells Fargo or Navy Fed. After that lump sum we're all the same, and if they want to restructure you or give you a new contract it won't matter if you WERE the senior partner or a junior partner.

2. Time - They meet ALL THE TIME for 1-2 hours, usually the board meetings begin at 7 or 8 PM. I have a wife and two children. Many hobbies.

3. Title - Means nothing me. People who like titles are baby boomers from the south and people who never deployed with the military.

4. Getting a vote for "stuff" - Matters if you're one of four other guys/gals...My practice has sixteen (I think) across all ortho specialties. What exactly am I getting with my vote? The partners know spine and total joint pays all the bills, so they want another spine surgeon or pain doctor to come in, but the spine surgeons and myself don't want more dudes in the group to take away our business...Doesn't matter because all those other dudes vote and we hire another spine surgeon or pain doctor...Those other partners do not care if the current spine surgeons or myself make less money because maybe the group makes a little more overall. "Oh, you're a partner...Cool, we're hiring another doctor because the group can support it. You may collect less money, but you can also leave the group if you choose." That happened to a partner 2 years ago...He left because of it.

Tell me more about destiny and who is on the menu...It varies considerably.

I show up for work and have zero strings tugging on me other than patient care. I have production bonuses and ASC money. I am protected from drug seekers, and have unlimited vacation time as long as I pay my overhead (easily done). There has never been one occasion I've had to "put in" for vacation or ask permission to go a conference. I take no call, no weekends, work 4.5 days a week.

 

[sloh]

It's interesting that nobody has brought up a growing cancer in the pain market: private equity groups.

Many of the docs I've met who work for these groups seem like good folks, but the outlook for a new doc joining them is...grim.

Can you elaborate more? Compensation, ceiling, schedule, etc etc.

 

[drusso]

It's interesting that nobody has brought up a growing cancer in the pain market: private equity groups.

Many of the docs I've met who work for these groups seem like good folks, but the outlook for a new doc joining them is...grim.

I'd love to talk to ANYONE who can get me 5-7X EBITA for my business. I don't know what else to say, but PM me. I'm "available."

 

[au bon pain]

Can you elaborate more? Compensation, ceiling, schedule, etc etc.

From the PE groups I've interviewed with, schedule seems to be typical daytime no nights/weekends. 40-50hrs/week in the office. 2-3 weeks of vacation+1 week CME. Call is often shared by the docs/midlevels from all the nearby offices -- you take it for 1 week at a time, but the "senior" docs typically don't have to take call.

Compensation is maybe more for the private forum, but some offered a base+collections and others offered straight % collections. I've seen it range from shockingly low to mediocre, with one group being an exception and offering something quite reasonable. You won't starve but they'll work you very hard and after several years you'll still likely make well below 50% MGMA. And while you generally have no prospect of meaningful ownership/partnership, they expect you to market like hell to build up their practice for them. They tend to have extremely restrictive non-competes to try to trap docs to keep them from leaving.

The docs I've met who are happy working in these settings are 1) folks whose practice was bought out/absorbed by PE and stayed on for way more $ than new hires will be able to earn over time and 2) new grads who are happy to just see patients and mingle with referral sources after hours while not really caring about how much somebody else is making off their work.

 

[au bon pain]

I'd love to talk to ANYONE who can get me 5-7X EBITA for my business. I don't know what else to say, but PM me. I'm "available."

If trends hold, a PE group who bought your practice would find ways to make care more expensive for your patients, strip away any "inefficient" aspects of your operation like counseling etc, and create a model where, outside of seeing new patients, you're standing in their ASC (if local laws let them open one) waiting for their midlevels to feed you procedures based on their ddx.

The utopia you're hoping for?

 

[Laryngospasm]

Not sure why anyone in their right mind would go for that. It’s one thing to not care what you make it’s another to be totally f’ed like that . I would quit before I did that or go back to anesthesia where I can make great money with 12 weeks vacation . At least if I work harder I can make 90%tile working for the hospital.

 

[Ronin1]

Private equity just pays you with your own money. Essentially if you are making 750 your new salary will be 450k with a 1.5-2 million equity event. But you get that payout as a long term capital gain. Usually you hav to stay for a certain length of time as well. Works better with bigger groups such as anesthesia.

 

[au bon pain]

Private equity just pays you with your own money. Essentially if you are making 750 your new salary will be 450k with a 1.5-2 million equity event. But you get that payout as a long term capital gain. Usually you hav to stay for a certain length of time as well. Works better with bigger groups such as anesthesia.

Seems like an accurate description if you sold to them. The tax advantages are a silver lining.

For a new grad, signing on seems to be a disproportionately worse deal.

 

[SommeRiver]

If trends hold, a PE group who bought your practice would find ways to make care more expensive for your patients, strip away any "inefficient" aspects of your operation like counseling etc, and create a model where, outside of seeing new patients, you're standing in their ASC (if local laws let them open one) waiting for their midlevels to feed you procedures based on their ddx.

The utopia you're hoping for?

...and all the while knowing you spent yrs on an internet forum talking about efficiency of care, patient safety, treatment in a timely manner, private practice being clean/cheap, SOS, etc...

I wouldn't judge you for it, but I'd laugh about it.

 

[drusso]

...and all the while knowing you spent yrs on an internet forum talking about efficiency of care, patient safety, treatment in a timely manner, private practice being clean/cheap, SOS, etc...

I wouldn't judge you for it, but I'd laugh about it.

I couldn't bring myself to do it...but if I did, I fantasize about a $65-70/wRVU gig, 60 minute ESI's, juicing the vig on $O$, clocking-in/clocking-out, raising pasture pets, working on home improvements for my passive income rental properties, and building race cars!

 

[SommeRiver]

I couldn't bring myself to do it...but if I did, I fantasize about a $65-70/wRVU gig, 60 minute ESI's, juicing the vig on $O$, clocking-in/clocking-out, raising pasture pets, working on home improvements for my passive income rental properties, and building race cars!

American dream in many ways - Build a company and sell it.

 

[nvrsumr]

Different strokes for different folks. Lots of happy docs with very different practice set ups.

I enjoy owning my practice and would encourage anyone to hang their shingle

 

[SommeRiver]

...so many different options.

I interviewed a few applicants who considered working in our group (we pulled the spot after I got better at my job and showed them I don't need any help). Interesting to hear expectations from ppl who've never done an epidural without an attending present in the room...

It seemed they all considered PP to automatically come with a guarantee of partnership, otherwise there's no reason to do it.

We all suffered years and years of training and finally graduate and now let's pay loans, get a house, buy the spouse a car (couldn't do it without him or her)...

Our group was formed 5 decades ago - You waltz in and 12 months later after collecting 500-600k you expect a piece of the pie? Why?

Tons of small pain practices, maybe 2 or 3 docs in the group and they may offer you partnership after you cut your teeth and show them you deserve it, but the ppl I met expected it in the GD contract.

You imagine hanging a shingle and fight to stay afloat and independent with all the encroachment...Some kid who hasn't even burned a medial branch nerve without supervision strolls through your doors and puts your reputation on the line and you're supposed to immediately reward them with partnership?

Fellowships do a poor job teaching trainees what it means to be an attending. Academic jobs are all that really matter, otherwise you're out to make money as a "local pain guy."

...but the conversation is always framed as if you're a partner and own the business bc why else would you do PP?

You can do PP (freedom) without being a partner and that may be the best fit for you.

My footprint in the community is no bigger if I'm a partner. I would see the same number of pts while doing the same number of shots, same SCS, orthobiologics same, etc...Money would be bigger, and in some cases that could be many hundreds of thousands more but there's no such thing as a free lunch - That extra money comes at a cost, and there's risk considering the feast or famine nature of being a small business owner.

 

[Status Sciaticus]

...so many different options.

I interviewed a few applicants who considered working in our group (we pulled the spot after I got better at my job and showed them I don't need any help). Interesting to hear expectations from ppl who've never done an epidural without an attending present in the room...

It seemed they all considered PP to automatically come with a guarantee of partnership, otherwise there's no reason to do it.

We all suffered years and years of training and finally graduate and now let's pay loans, get a house, buy the spouse a car (couldn't do it without him or her)...

Our group was formed 5 decades ago - You waltz in and 12 months later after collecting 500-600k you expect a piece of the pie? Why?

Tons of small pain practices, maybe 2 or 3 docs in the group and they may offer you partnership after you cut your teeth and show them you deserve it, but the ppl I met expected it in the GD contract.

You imagine hanging a shingle and fight to stay afloat and independent with all the encroachment...Some kid who hasn't even burned a medial branch nerve without supervision strolls through your doors and puts your reputation on the line and you're supposed to immediately reward them with partnership?

Fellowships do a poor job teaching trainees what it means to be an attending. Academic jobs are all that really matter, otherwise you're out to make money as a "local pain guy."

...but the conversation is always framed as if you're a partner and own the business bc why else would you do PP?

You can do PP (freedom) without being a partner and that may be the best fit for you.

My footprint in the community is no bigger if I'm a partner. I would see the same number of pts while doing the same number of shots, same SCS, orthobiologics same, etc...Money would be bigger, and in some cases that could be many hundreds of thousands more but there's no such thing as a free lunch - That extra money comes at a cost, and there's risk considering the feast or famine nature of being a small business owner.

why wouldnt they? It seems that theres nothing stopping private practice partners from screwing over the new hires after they put in their 2-3 years. Fire them or tell them theyre not going to make partner right before the "audition period" ends. its predatory behavior and theres nothing stopping you. Your words dont mean much, but legally binding contracts do.

 

[SommeRiver]

why wouldnt they? It seems that theres nothing stopping private practice partners from screwing over the new hires after they put in their 2-3 years. Fire them or tell them theyre not going to make partner right before the "audition period" ends. its predatory behavior and theres nothing stopping you. Your words dont mean much, but legally binding contracts do.

...all true and happens frequently, but I still don't see why a new grad feels he/she automatically deserves a guaranteed path to partnership.

You've done nothing but finish your formal training. So what? Your practice will not start making legit money off you for another 2 to 3 yrs.

Nearly all pain fellow grads suck at their job for a few years, and I bet most pain docs who disagree are those in year 2 post fellowship.

When pts come in today who've not been seen in 2 yrs I read those old notes and groan! "Look at that contrast pattern," and "I did what?"

Risk of being screwed is not limited to PP; it happens in all avenues of physician employment in one way or another.

 

[gdub25]

I have never understood why guys are totally fine with working for a hosptial and making them tons of money but if they work for a private group they feel they’re getting screwed if not offered partnership. I am in 100% agreement with SommeRiver. The way I look at it the doc who is employed by the PP group is at least practicing in a lower cost setting than they guy employed by the hosptial. Employment is employment, regardless of who your boss is. Some bosses are good, others bad, and this can be hosptial admins or the PP owner. For some reason we keep spreading this false narrative that hospital admins as bosses are a necessary evil in the otherwise totally fair and acceptable hospital employee model and employment by a PP is unfair and the deck is stacked against you.

 

[afob100]

I have never understood why guys are totally fine with working for a hosptial and making them tons of money but if they work for a private group they feel they’re getting screwed if not offered partnership. I am in 100% agreement with SommeRiver. The way I look at it the doc who is employed by the PP group is at least practicing in a lower cost setting than they guy employed by the hosptial. Employment is employment, regardless of who your boss is. Some bosses are good, others bad, and this can be hosptial admins or the PP owner. For some reason we keep spreading this false narrative that hospital admins as bosses are a necessary evil in the otherwise totally fair and acceptable hospital employee model and employment by a PP is unfair and the deck is stacked against you.

The difference is the actual salary. Hospitals will offer starting salaries that are closer to 50% mgma than pp. Pp groups can't afford to start salary as high. So why should a new grad take a lower salary for 2 years for some false promise of partnership.

Instead, why can't pp offer an employee track position with no chance of partnership with a starting salary close to 400k plus production bonus if certain metrics are met. Ive never seen a pp job posting/offer like that.

The only reason to take a low starting salary of pp is if there is opportunity for partnership and the low salary for 2-3 years is your "buy in."

 

[Laryngospasm]

Personally I worked harder for a private practice group and made less with less benefits and vacation and the partnership that was promised withdrawn. I don’t think anyone thinks working for hospitals is perfect and I’m definitely not saying that. But I get paid for what I do and have good benefits and well as more vacation. Tail, Heath for me and my family, retirement etc. I think ideally a lot of us would like to own our own practice but this has become difficult in many locations. And yes making the hospital tons of money sucks and I wish I got more of it.. definitely.

 

[au bon pain]

...all true and happens frequently, but I still don't see why a new grad feels he/she automatically deserves a guaranteed path to partnership.

You've done nothing but finish your formal training. So what? Your practice will not start making legit money off you for another 2 to 3 yrs.

Nearly all pain fellow grads suck at their job for a few years, and I bet most pain docs who disagree are those in year 2 post fellowship.

When pts come in today who've not been seen in 2 yrs I read those old notes and groan! "Look at that contrast pattern," and "I did what?"

Risk of being screwed is not limited to PP; it happens in all avenues of physician employment in one way or another.

I worked for years in a different field before returning to do fellowship, and I completely agree with you that new grads shouldn't expect a guaranteed path to partnership on day one.

Rather, the biggest problem I've found when interviewing with PP groups are overly restrictive non-competes. If they eventually decide I'm not worthy of partnership, I get it and life goes on...but don't twist the knife by forcing me to uproot my family and move in order to keep practicing pain. I've come to view these crazy non-competes as a bigger sign that in the future the group could rely on a stick, rather than a carrot, to keep me around. Very predatory and a huge red flag IMHO.

 

[SommeRiver]

The difference is the actual salary. Hospitals will offer starting salaries that are closer to 50% mgma than pp. Pp groups can't afford to start salary as high. So why should a new grad take a lower salary for 2 years for some false promise of partnership.

Instead, why can't pp offer an employee track position with no chance of partnership with a starting salary close to 400k plus production bonus if certain metrics are met. Ive never seen a pp job posting/offer like that.

The only reason to take a low starting salary of pp is if there is opportunity for partnership and the low salary for 2-3 years is your "buy in."

That practice is investing money in you early on; you will cost them money for 12-18 months.

So many fellowship grads think they're ready to kill it on day one, but they don't know what they don't know.

My residency (Emory PMR) frequently graduates people who go straight into PP pain without fellowship.

I could have done the same, but I wanted to make sure I was on the up and up, had an ACGME certificate, etc...

By the time I finished fellowship I was ready to kill it - But I didn't know anything (still don't know as much as I want).

I had no clue had to be an attending.

My first yr I was inefficient and collected 650? Something like that...Considering my group is huge, we can eat money on a new doctor for awhile, especially if that doctor is motivated and trying to get better.

I collect a lot more now, so we're all happy.

If my group was a stand alone pain practice with 4 other doctors that initial 650k in collections just cost the partners money. They lose money on me that year.

They will continue to lose money on me until I am collecting a million or more dollars.

One million is an arbitrarily chosen amount, but most pain groups need that doctor collecting something along that number to be successful. Until you reliably hit numbers like that you don't get partnership.

I am huge on small business. It is what keeps this country afloat, and I young doctors coming out of fellowship need to understand and appreciate what it means to start a small business and keep it running successfully.

There is a ton of risk involved.

Edit - Let me add another thing...In my group, I have no one to help me. There are other pain docs but they're slow and don't do anything. One is utterly horrendous at his job and sucks...

So I'm the young guy and I brought new ideas and techniques, but the spine surgeons have no idea WTF I'm about or what I do...They also won't listen.

In a hospital there are ppl there who can probably help you. Like, other pain doctors perhaps.

Even though I'm in a big group, I am completely alone in the practice of pain. Urgent surgery is easy. My spine surgeons are very available for that. If something happened I have back up...But how to manage pain pts, set up a clinic, trouble shooting procedures, scrub in on first few stim cases to make sure I'm ready...None of that.

I have had to do it on my own.

It is more than reasonable to work at a PP with a few other pain docs who can help you learn the job.

 

[SommeRiver]

I worked for years in a different field before returning to do fellowship, and I completely agree with you that new grads shouldn't expect a guaranteed path to partnership on day one.

Rather, the biggest problem I've found when interviewing with PP groups are overly restrictive non-competes. If they eventually decide I'm not worthy of partnership, I get it and life goes on...but don't twist the knife by forcing me to uproot my family and move in order to keep practicing pain. I've come to view these crazy non-competes as a bigger sign that in the future the group could rely on a stick, rather than a carrot, to keep me around. Very predatory and a huge red flag IMHO.

I can understand this completely.

I have a 25 mile non-compete, but I'm rural and it would not have any impact on my future employment.

We understand that my not working in my group means moving to Atlanta, or back towards home in Savannah.

If you live in NYC or LA or something, and if you're from there and want to stay there I see that as an issue.

 

[BobBarker]

There is just a lot more meat on the bone with the SOS differential in favor of the hospital employment track. Better salaries, bonuses, benefits, etc with hospital employment. They don’t care about losing $100k on physician production vs salary for the first several years as they still are making money off the total sum of physician system impact.

 

[drusso]

There is just a lot more meat on the bone with the SOS differential in favor of the hospital employment track. Better salaries, bonuses, benefits, etc with hospital employment. They don’t care about losing $100k on physician production vs salary for the first several years as they still are making money off the total sum of physician system impact.

Yep, they track it. And, they will never love you back. It's just what how much money you're bringing to the bottom line that matters.

 

[lobelsteve]

Yep, they track it. And, they will never love you back. It's just what how much money you're bringing to the bottom line that matters.

You would never love me back. Big spoon.

 

[paindoc007]

Yep, they track it. And, they will never love you back. It's just what how much money you're bringing to the bottom line that matters.

Meh, it’s a job bro. Not your kids or wife. I don’t need to be loved. I work X hours, generate Y income for hospital, and make Z for myself.

 

[afob100]

That practice is investing money in you early on; you will cost them money for 12-18 months.

So many fellowship grads think they're ready to kill it on day one, but they don't know what they don't know.

My residency (Emory PMR) frequently graduates people who go straight into PP pain without fellowship.

I could have done the same, but I wanted to make sure I was on the up and up, had an ACGME certificate, etc...

By the time I finished fellowship I was ready to kill it - But I didn't know anything (still don't know as much as I want).

I had no clue had to be an attending.

My first yr I was inefficient and collected 650? Something like that...Considering my group is huge, we can eat money on a new doctor for awhile, especially if that doctor is motivated and trying to get better.

I collect a lot more now, so we're all happy.

If my group was a stand alone pain practice with 4 other doctors that initial 650k in collections just cost the partners money. They lose money on me that year.

They will continue to lose money on me until I am collecting a million or more dollars.

One million is an arbitrarily chosen amount, but most pain groups need that doctor collecting something along that number to be successful. Until you reliably hit numbers like that you don't get partnership.

I am huge on small business. It is what keeps this country afloat, and I young doctors coming out of fellowship need to understand and appreciate what it means to start a small business and keep it running successfully.

There is a ton of risk involved.

Edit - Let me add another thing...In my group, I have no one to help me. There are other pain docs but they're slow and don't do anything. One is utterly horrendous at his job and sucks...

So I'm the young guy and I brought new ideas and techniques, but the spine surgeons have no idea WTF I'm about or what I do...They also won't listen.

In a hospital there are ppl there who can probably help you. Like, other pain doctors perhaps.

Even though I'm in a big group, I am completely alone in the practice of pain. Urgent surgery is easy. My spine surgeons are very available for that. If something happened I have back up...But how to manage pain pts, set up a clinic, trouble shooting procedures, scrub in on first few stim cases to make sure I'm ready...None of that.

I have had to do it on my own.

It is more than reasonable to work at a PP with a few other pain docs who can help you learn the job.

Question though- why can't a pp group spell out some specific metrics to hit to become a partner (ie if you hit $1 mil collections by end of year 3, we plan to offer you partnership)?

Instead of "here's $300k/yr for 3 years and let's see what happens."