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

[SommeRiver]

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."

Not unreasonable, but what about personality fit or any other number of issues that would make a practice move on from someone?

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[afob100]

Not unreasonable, but what about personality fit or any other number of issues that would make a practice move on from someone?

Honestly if a potential partner is bringing in $1 mil+ in collections, does personality matter. At the end of the day, it's a business and you all want to make money. Who cares if you wouldn't go golfing with him/her on the weekend....

 

[gdub25]

True but other issues come into play like do they treat the staff well, so they practice good medicine, do they maintain the same good reputation that the practice is trying to represent, are they an HR nightmare because they say inappropriate things to the staff or reps...all things we have to consider when thinking about someone as a partner. Once you a married to them in the business it’s very difficult to divorce.

 

[gdub25]

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."

Any practice should put some basic expectations out in the open, I agree. We always been advised it’s not legal to put these metrics in writing but have a one page written agreement that partnership will be available and open to discussion at the end of the contract or before if performance is supportive.

 

[DrMDAware]

...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 agree with you that it is foolish for a new grad to think they can come out and command the same salary as others who have put in more time and risk. I understand that it takes 18-24 months for the new person to start bringing in revenue.

With that being said, I hold there may be a better way to bring someone new on board as opposed to showing them the door at 3 years. This is just stringing them along. There should be milestones along the way to let them know they are progressing appropriately. The metrics must be spelled out. Some guidance, support, or mentorship should help accelerate the growth. Of course, a decent base salary and potential to get a cut as more revenue is brought in.

In addition, that new grad should not expect the owners/partners to teach them business. It is encumbent upon the new grad to understand EBITDA, A/R, amortization, tax write offs, reimbursement codes, supply costs, insurances prices, organizational behavior, how to talk to patients, etc. There are books and videos on this stuff.

Now, what is a respectful way for a new grad to join a practice? Here's my thought. Have that person show the group his or her value. For example, can the new person bring in a new procedure, understand SEO better, use social media better for marketing, create more efficient templates and workflows, go after a new referral source, leverage connections from residency/fellowship, teach about new techniques, etc. The point is the new person ought to bring something that the group doesn't already have. What I mean is that new grad should not expect to do TFESIs and make the same amount of money. It is redundant. The existing practice should see value in what this person offers. It is a win-win. This is rare. But I've seen it.

Where I think there is some disconnect between PP and hiring a new grad is as follows. Does the group want someone to write opioids only? See the poorly insured patients? Do the low-yielding procedures? Take call? Do follow-up calls? You get the idea. Those can all be delegated to someone who doesn't command an MD/DO type salary. An NP/PA/MA/part-time person could handle those tasks IMO without the higher salary. What I'm saying is if the new grad doesn't bring much to the table then he or she cannot make the case to be renumerated in such a way.

 

[drusso]

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."

Because partnership is not only about finances. It's about trust. It's a bro-mance. The associate could be a douche bag.

 

[gdub25]

You are exactly right DrMDAware! I spend a lot of time volunteering and teaching fellows courses to help them understand this. I believe we should stop being hosptial employees and more of our grads should be going into PP but for this to happen we have to educate them on the real world.

When I graduated the job I took was this: I got to keep 33% of my collections with the understanding that when I was collecting enough to cover my own overhead we would discuss partnership. Partnership simply meant that I would become a straight eat what you kill earner and we would all split overhead equally. I had no salary guarantee. To make ends meet for the first few months the docs I joined offered to loan me money on a monthly basis interest free until I had some collections rolling in. I loved the deal because it gave me an opportunity to benefit from a well organized practice in terms of scheduling, billing, etc while at the same time affording me the opportunity to show what I could do. They didn’t give me any patients and I didn’t expect them to. Referrals coming in with “first available” would come to me but those were few and far between because my partners had personal relationships with the referring docs. When I got one I was thankful and kept hustling. I went out every day and knocked on doors, established new relationships in a new market, and proved my worth like DrMDAware has described. In my case I was fortunate to be able to “prove my worth” in less than a year. Every person in my group has been offered the same deal since the founding partner brought on the first one of us. We actually recently adjusted the percent of collections to a tiered structure of 33-40-45% as you collect more since overhead is less the more you collect. This makes it more fair for the new hire we feel like.

So, who out there would take a job with zero salary like me and all my partners did?

 

[DrMDAware]

You are exactly right DrMDAware! I spend a lot of time volunteering and teaching fellows courses to help them understand this. I believe we should stop being hosptial employees and more of our grads should be going into PP but for this to happen we have to educate them on the real world.

When I graduated the job I took was this: I got to keep 33% of my collections with the understanding that when I was collecting enough to cover my own overhead we would discuss partnership. Partnership simply meant that I would become a straight eat what you kill earner and we would all split overhead equally. I had no salary guarantee. To make ends meet for the first few months the docs I joined offered to loan me money on a monthly basis interest free until I had some collections rolling in. I loved the deal because it gave me an opportunity to benefit from a well organized practice in terms of scheduling, billing, etc while at the same time affording me the opportunity to show what I could do. They didn’t give me any patients and I didn’t expect them to. Referrals coming in with “first available” would come to me but those were few and far between because my partners had personal relationships with the referring docs. When I got one I was thankful and kept hustling. I went out every day and knocked on doors, established new relationships in a new market, and proved my worth like DrMDAware has described. In my case I was fortunate to be able to “prove my worth” in less than a year. Every person in my group has been offered the same deal since the founding partner brought on the first one of us. We actually recently adjusted the percent of collections to a tiered structure of 33-40-45% as you collect more since overhead is less the more you collect. This makes it more fair for the new hire we feel like.

So, who out there would take a job with zero salary like me and all my partners did?

Thanks for spending your time volunteering and teaching the fellows.

I'd love to see any PowerPoint presentations or handouts you might have.

Any chance you could send them to me? We need more people to know about these kinds of things IMHO.

And great job to you hustling and intelligently using the already established resources from the group (ie scheduling, billing).

 

[SommeRiver]

Honestly if a potential partner is bringing in $1 mil+ in collections, does personality matter. At the end of the day, it's a business and you all want to make money. Who cares if you wouldn't go golfing with him/her on the weekend....

There are many ways a partner can bring toxicity to the group. What if he collects a lot but loves the booze? Tons of extracurricular stuff that can cause problems with your brand.

 

[Tboned]

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."

This is my setup. Not as high starting salary but higher wRVU conversion hospital than other hospital gigs I looked into. Have the Option to buy into ASC and other real estate with group but no partnership

 

[Nodolor]

Not unreasonable, but what about personality fit or any other number of issues that would make a practice move on from someone?

If there was a personality issue why would the Doc still be there after 3 years?

 

[DrSpine]

Despite all the headaches of owning your own practice, I am still a proponent of it. I grew up in an entrepreneurial spirit household, surrounded constantly by friends and family who promote success and business ownership, etc. I’ve always been born and raised of the mindset that I need to own my practice and be a business owner to be successful. I don’t like being told what to do, and I always believe there’s a better way of doing it. Most importantly, I find work much more exciting when I am in the cockpit dealing with it and having projects. When it’s completed and you see all the hard work you put into something is built into a successful venture, it’s so rewarding. When I was a child, I remember going to the Doctor office, where they owned their practice and were skilled at their trade and successful, while also being respected and revered. Look, maybe that image is dying, but I grew up on that dream and want to pursue that. Sure not everyone wants to deal with it; some people are content with clocking in/clocking out, being told what to do, and giving a large portion of what they bring in away in exchange of not being a “business” person. That’s okay. But not everyone is like that, and while it’s scary opening up a practice, scared money never makes money. Physicians today I noticed are less entrepreneurial, and far more scared of the real world. No wonder why the void was filled by private equity and hospital administrators. These are the same people today who told me “don’t pick stocks, keep up with loser index funds.” My returns have eclipsed any index fund because I recognized the perfect storm and bubble that came our way; sure it’s hard to predict everything, but having a sharp business acumen goes a long way. Best of all, being in control of your destiny leaves you to well - you. Which means you work harder, and God Forbid if things don’t work out, it’s on you. Also, you’re not forced or pressured into doing anything you don’t want to do.

TL;DR Start off employed either via Hospital or PP, then exit off and do your own thing. That’s my philosophy.

 

[Nodolor]

Doctors are our own worst enemy. We eat our young, turn them and then burn them. Greed is a major problem and that causes many Docs to screw others to pad their bottom line.

 

[DrSpine]

Doctors are our own worst enemy. We eat our young, turn them and then burn them. Greed is a major problem and that causes many Docs to screw others to pad their bottom line.

Agreed. I had horrific experiences when I was out and looking for jobs with PPs. Ridiculous.

 

[Nodolor]

Agreed. I had horrific experiences when I was out and looking for jobs with PPs. Ridiculous.

Yes currently looking for a new position after running my own practice for 13 years....lots of shady, weird stuff out there

 

[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.

It used to be so easy to advocate for physician interests when we were all independent. Same boat; same storm. Only the Kaiser doctors were outliers.

Now, with more doctors just clocking-in/clocking-out and working for the Man, they've turned us against each others. Things like $O$ reform, price transparency, and strong anti-kickbacks/Stark used to be good for all doctors. Now, some hospital employed MD's get to juice the vig on the $O$, obscure billing practices, and cost shifting/kicks backs/ arbitrage. Some doctors are winners and other are just left holding their d#ck's in their hands.

Ultimately, all patients lose.

 

[DrMDAware]

Hey y'all just following up what I noticed was the deals were different in different parts of the country. I finally signed in a rural part of the US in the southeast....Like what was said beforeI was surprised at some places some hospital gigs were much nicer than PP gigs but in other places PP gigs blew the hospital gig out the water. Like others have said it really depends on a case by case basis and knowing what you want and where you want to be in a couple of years.

 

[NJPAIN]

Doctors are our own worst enemy. We eat our young, turn them and then burn them. Greed is a major problem and that causes many Docs to screw others to pad their bottom line.

I believe that this problem is worse in our field than most. There is an epidemic of greed amongst us.

 

[mja75]

There's no right answer to this age old question. I know very happy pain physicians in both settings (and very unhappy ones). The key is finding a good job that respects your life outside the job and those are hard to find, regardless of specialty or setting. Find that job that generates you the most money with the least time investment in a place that you don't hate with people that you don't hate. If you're able to pull back the lens this far, you'll see plenty of opportunities. You will be happy in either setting as long as you understand the terms of your existence there. In my own biased opinion, hospital employment is a superb option for pain medicine trained anesthesiologists.

 

[DrMDAware]

There's no right answer to this age old question. I know very happy pain physicians in both settings (and very unhappy ones). The key is finding a good job that respects your life outside the job and those are hard to find, regardless of specialty or setting. Find that job that generates you the most money with the least time investment in a place that you don't hate with people that you don't hate. If you're able to pull back the lens this far, you'll see plenty of opportunities. You will be happy in either setting as long as you understand the terms of your existence there. In my own biased opinion, hospital employment is a superb option for pain medicine trained anesthesiologists.

Thx for sharing...do u mind explaining this? I am genuinely curious to hear ur thoughts.

 

[drusso]

In my own biased opinion, hospital employment is a superb option for pain medicine trained anesthesiologists.

Why????

 

[sdnuser001]

Thx for sharing...do u mind explaining this? I am genuinely curious to hear ur thoughts.

Why specifically anesthesiologists?

 

[sdnuser001]

There's no right answer to this age old question. I know very happy pain physicians in both settings (and very unhappy ones). The key is finding a good job that respects your life outside the job and those are hard to find, regardless of specialty or setting. Find that job that generates you the most money with the least time investment in a place that you don't hate with people that you don't hate. If you're able to pull back the lens this far, you'll see plenty of opportunities. You will be happy in either setting as long as you understand the terms of your existence there. In my own biased opinion, hospital employment is a superb option for pain medicine trained anesthesiologists.

Why specifically anesthesiologists?

 

[DOctorJay]

I’m finally starting to get a deep dive into what’s going on at my hospital and am seeing how the money flows.

Not all hospital jobs are created equal and you aren’t guaranteed to get any piece of that SOS fee baked into your wRVU valuation.

I’m employed by a physician group which is a separate entity (for profit) from the hospital (non-profit). Because we’re separated the physician group doesn’t see any of the facility fees and doesn’t really care what’s generated on that side. So we end up getting a percentage of our professional fees only.

What ends up happening is your professional fees are decreased because you’re doing procedures in an HOPD setting. We’ve asked to convert our suites into office based instead as it will generate more revenue for the physician group (and in turn us) but they said no.

So for the graduating fellows entertaining offers please figure this out before you sign with a hospital.

When I took this job it was structured as base salary or 75% of net patient revenue (pro fees) whichever was higher. Things have changed and I’ve learned more and we’re still only getting a percentage of our pro fees (nothing additional from the SOS).

 

[BobBarker]

So one independent entity is intentionally harming itself and it’s employees for the benefit of another independent entity. All so they can use the excuse that the two pots are separate.

 

[Agast]

I’m finally starting to get a deep dive into what’s going on at my hospital and am seeing how the money flows.

Not all hospital jobs are created equal and you aren’t guaranteed to get any piece of that SOS fee baked into your wRVU valuation.

I’m employed by a physician group which is a separate entity (for profit) from the hospital (non-profit). Because we’re separated the physician group doesn’t see any of the facility fees and doesn’t really care what’s generated on that side. So we end up getting a percentage of our professional fees only.

What ends up happening is your professional fees are decreased because you’re doing procedures in an HOPD setting. We’ve asked to convert our suites into office based instead as it will generate more revenue for the physician group (and in turn us) but they said no.

So for the graduating fellows entertaining offers please figure this out before you sign with a hospital.

When I took this job it was structured as base salary or 75% of net patient revenue (pro fees) whichever was higher. Things have changed and I’ve learned more and we’re still only getting a percentage of our pro fees (nothing additional from the SOS).

Is the base salary paid for by the hospital or the physician group? If it’s the hospital they should at least be setting a good base to account for how much they make off of you.

 

[DOctorJay]

Is the base salary paid for by the hospital or the physician group? If it’s the hospital they should at least be setting a good base to account for how much they make off of you.

Physician group. It is a good base at this point but the bonus structure above that is not good.

 

[NJPAIN]

Physician group. It is a good base at this point but the bonus structure above that is not good.

Who hires and pays the manager of your “service line” who essentially controls what you do and how you do it? The physician group or the hospital?

 

[Agast]

Physician group. It is a good base at this point but the bonus structure above that is not good.

If you’re only get a percentage of the professional fees and everything is hospital based, the physician group must be getting some supplemental payment from the hospital back. Otherwise you’d be at like 10-percentile MGMA salary.

 

[DOctorJay]

Who hires and pays the manager of your “service line” who essentially controls what you do and how you do it? The physician group or the hospital?

I believe the physician group but I’m not certain there.

 

[DOctorJay]

If you’re only get a percentage of the professional fees and everything is hospital based, the physician group must be getting some supplemental payment from the hospital back. Otherwise you’d be at like 10-percentile MGMA salary.

This is probably true since there is a significant “loss” from our service line.

 

[bedrock]

This is probably true since there is a significant “loss” from our service line.

That is BS. they should bring everything inside the hospital pay system and pay you via RVU, or at least further increase your pro fee percentage.

 

[DOctorJay]

That is BS. they should bring everything inside the hospital pay system and pay you via RVU, or at least further increase your pro fee percentage.

So I probably wasn’t clear but we do track wrvus and are bonused off of that for productivity but instead of $/wRVU we get a set dollar amount for each wRVU percentile above the 60th percentile to the 80th.

So what happens is the value of each wrvu actually goes down the more you produce.

We no longer are paid a percentage of net revenue.

 

[NJPAIN]

The simplest way to fix this is to realize that physicians bring business to the hospital; virtually ALL of the business. If you want our business:

- Treat us like customers
- Keep your hands out of our pockets

That’s how it was for decades. Then they decided that we are the dumbest bunch of highly educated people on earth and it would be so easy to take advantage of us. Now they play the shell game with us and we loose over and over again knowing that it’s rigged. We are afraid to call them a bunch of cheaters and thieves because we know that if they throw us out there are ten other doctors waiting for a seat at the gaming table. Divide and conquer strategy has worked really well.

 

[thecentral09]

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.

And all of this comes out an opportunity cost of doing something else it is important to you. Personally, I am young, hospital employed come work in a rural area, and have two very small children. I’m reimbursed at 75% MGMA as a base salary no matter what I bring in. I can’t fathom trying to work with all the intricacies of private practice while also having a wife who still likes me and being a part of 2 young kids lives
Secondly, the opportunity cost of direct ownership and running a practice also ensures we probably won’t have time to do anything else that you either want to do or makes money. I spend the approximately 5 to 10 hours per week on personal investment(ie stocks) stuff that I no way would be able to do if being the sole owner of a private practice. So for me, boiling it all down into reimbursement per hour of total time worked favors hospital in my case, but I also understand others are in different circumstances

 

[thecentral09]

The simplest way to fix this is to realize that physicians bring business to the hospital; virtually ALL of the business. If you want our business:

- Treat us like customers
- Keep your hands out of our pockets

That’s how it was for decades. Then they decided that we are the dumbest bunch of highly educated people on earth and it would be so easy to take advantage of us. Now they play the shell game with us and we loose over and over again knowing that it’s rigged. We are afraid to call them a bunch of cheaters and thieves because we know that if they throw us out there are ten other doctors waiting for a seat at the gaming table. Divide and conquer strategy has worked really well.

The game changed because now there are 10 others that would jump in in our place and do the job for what administration thinks it should be paid. That was probably not the case 15 years ago

 

[Laryngospasm]

Dollar value per rvu should not go down the more you earn. That’s pure greed on the hospitals part. The hospital has a fairly steady overhead which is more than covered by you earning up to the average.. to pay you less for the rvus above that is ridiculous. Mine is steady all the way up. Unless you are getting way overpaid on the first 560rvus which I’m pretty sure you aren’t.

 

[MiddleOfNowherrr]

Hospitals can *afford* to pay u more...but DO they? Our group is independent contractors with the hospital here and I couldnt imagine being 100% their employee (our current status Im only marginally ok with bc I work part time and debating getting my JD anyway so for now I just deal). The semi-independence I have means the world to me, and there is NO WAY I would be happy working for the suits and admin that have NO IDEA how to run an efficient practice. They dont care about hiring good staff (or about getting rid of bad staff). They just stick warm bodies into your clinic, give you 3-5 less exam rooms- and minimal supplies- than u need for your group, set unattainable quality/quantity metrics, force u to teach NPPs who they then hire to replace u, force u to waste your time with ER or Inpatient consults, find ways NOT to pay u your full RVUs or lower your salary in some form or fashion....the list goes on and on. Our competitors are doing better than us bc referring providers dont like all the NPPs and hospital bureacracy that come with a referral to us. Succumbing to full employment by these greedy arse hospitals is one of the fundamental problems we have in medicine. We have let go of all of our autonomy which sacrifices the field of medicine for the all important $$$ and also hurts the patients. Im terrified of what medicine will have become for me as I age or for my children as they grow older. So yea im all about PP. Just do procedures at a free standing ASC that u own shares in. Also, the biggest insurance payor here recently threatened to no longer reimburse at the hospital rate for pain procedures done at our hospital surgery center...so now all the suits are scrambling to see how to “rectify” this before they enforce this and all the others follow. Hospitals only know how to suck u dry of every ounce of energy and passion u ever thought u had for working in medicine and helping your patients. Its always best to be your own boss.
we also have to think about what capitated contracts will do to our earning potential as those continue gaining popularity. Its not all about the $, I know, but still soon it’s not going to be financially worth it anymore to join a hospital system.

 

[MiddleOfNowherrr]

Don’t forget you get paid the rvus whether the hospital does or not.. in PP you only get paid if insurance pays.

Thats if they pay u the RVUs u are owed. They jip us every. Single. Month

 

[drusso]

That is BS. they should bring everything inside the hospital pay system and pay you via RVU, or at least further increase your pro fee percentage.

How would that help make health care affordable? It's SOS arbitrage.

 

[drusso]

The simplest way to fix this is to realize that physicians bring business to the hospital; virtually ALL of the business. If you want our business:

- Treat us like customers
- Keep your hands out of our pockets

That’s how it was for decades. Then they decided that we are the dumbest bunch of highly educated people on earth and it would be so easy to take advantage of us. Now they play the shell game with us and we loose over and over again knowing that it’s rigged. We are afraid to call them a bunch of cheaters and thieves because we know that if they throw us out there are ten other doctors waiting for a seat at the gaming table. Divide and conquer strategy has worked really well.

 

[NJPAIN]

Hospitals can *afford* to pay u more...but DO they? Our group is independent contractors with the hospital here and I couldnt imagine being 100% their employee (our current status Im only marginally ok with bc I work part time and debating getting my JD anyway so for now I just deal). The semi-independence I have means the world to me, and there is NO WAY I would be happy working for the suits and admin that have NO IDEA how to run an efficient practice. They dont care about hiring good staff (or about getting rid of bad staff). They just stick warm bodies into your clinic, give you 3-5 less exam rooms- and minimal supplies- than u need for your group, set unattainable quality/quantity metrics, force u to teach NPPs who they then hire to replace u, force u to waste your time with ER or Inpatient consults, find ways NOT to pay u your full RVUs or lower your salary in some form or fashion....the list goes on and on. Our competitors are doing better than us bc referring providers dont like all the NPPs and hospital bureacracy that come with a referral to us. Succumbing to full employment by these greedy arse hospitals is one of the fundamental problems we have in medicine. We have let go of all of our autonomy which sacrifices the field of medicine for the all important $$$ and also hurts the patients. Im terrified of what medicine will have become for me as I age or for my children as they grow older. So yea im all about PP. Just do procedures at a free standing ASC that u own shares in. Also, the biggest insurance payor here recently threatened to no longer reimburse at the hospital rate for pain procedures done at our hospital surgery center...so now all the suits are scrambling to see how to “rectify” this before they enforce this and all the others follow. Hospitals only know how to suck u dry of every ounce of energy and passion u ever thought u had for working in medicine and helping your patients. Its always best to be your own boss.
we also have to think about what capitated contracts will do to our earning potential as those continue gaining popularity. Its not all about the $, I know, but still soon it’s not going to be financially worth it anymore to join a hospital system.

How does being an independent contractor work in that situation? Do you just get a salary to staff the clinic and do all your procedures in a hospital owned facility?

 

[NJPAIN]

The game changed because now there are 10 others that would jump in in our place and do the job for what administration thinks it should be paid. That was probably not the case 15 years ago

Exactly. They have done a great job convincing us that our work is worthless and that they are the customers that need satisfying, not us.

 

[bimmer79]

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.

Now here's the difference between PP and Hospital.

Hospital Pros:
Pays more up front than PP. Covers malpractice and tail. Good benefits, retirement, steady job, etc. Great for experience, referrals, etc.
Hospital Cons:
1 - Administration. I cannot stress enough about this. This is the most annoying part. You are not a respected Physician, you're merely a Ford assembly line worker in their eyes. They will tell you what to do, and if you don't want to do it, now comes the passive aggressiveness and meetings. If they have a certain vision, that's it. They'll falsely have a meeting with you telling you what your thoughts are, you're really supposed to say it's a "great idea" and you're "willing with work it."
2- Everything is about productivity; ie hamster going around the wheel. Look around, see the physicians who are 45, chances are, they're exhausted, miserable, and feel "Stuck." You also aren't getting any benefit to this work; you're not owning anything or building equity in anything. Clock in/clock out mentality.
3 - Ultimately a scam. First 1-2 years are "golden cuffs." Solid base to start you off, with productivity goals you're never really made to meet. Once you're off the guarantee, you find yourself working like a dog, constantly to meet/chase "RVUs." That golden 4-6 week vacation? Lasted 2 years, because after that, taking vacation cuts into your RVU productivity numbers.
4 - Some hospitals want call/inpatient consults. Those are brutal, you're better off bailing from that gig.
5 - Sometimes you're forced to work with people you don't agree with clinically.
6 - Inability to control variables or anything with the practice. What you want doesn't mean you'll get it, or it could take forever. Best part? Ultimately when things flop, you will be blamed for why "things aren't growing."
7 - Doesn't matter how much money you bring in, you'll constantly be told you're not bringing in enough revenue. They have to keep that pressure on you to keep producing and working to bring them in money.

Private Practice Pros:
1 - More voice.
2 - What you want, so long as its reasonable in the budget, will happen quickly.
3 - More innovative procedures I've noticed.
4 - No Administration.
5 - You are the Physician amongst the others who own the practice or are employed by the practice. Your voice is often more important. (Assuming this a non-private equity backed gig).

Private Practice Cons:
1 - Less money than Hospital.
2 - I notice many won't cover tail malpractice.
3 - Promise of partnership isn't necessarily true and you can be cut right before you're scheduled to become a partner or have the ability to buy in.
4 - No access to books obviously unless a partner.

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

I would agree in general with most of this, but my experience having been in 2 private practices, is that administration still plays a role. After all, their main goal is numbers/productivity. They don't understand clinical work or frankly don't care... their only concern is numbers. As long as you're employed, you likely won't get your fair share and will feel exploited.

 

[NJPAIN]

I don’t know what graduating fellows are finding. It seems to me that the field is so flooded (perhaps by non-ACGME interventional spine”fellowship” trained docs) that the only jobs available in half way desirable locations are medical Mgmt jobs. I’ve inquired about two jobs in the last week, one in WA and the other in CA. Both responded leading with- “ in the interest of not wasting your time.... this is a medical management job with minimal in office simple procedures (TPI, GON)”. On further investigation each facility has both anesthesiologists and PM&R doing interventions and looking for a sucker to deal with the meds and take a bullet for the team.

 

[DrSpine]

I’m finally starting to get a deep dive into what’s going on at my hospital and am seeing how the money flows.

Not all hospital jobs are created equal and you aren’t guaranteed to get any piece of that SOS fee baked into your wRVU valuation.

I’m employed by a physician group which is a separate entity (for profit) from the hospital (non-profit). Because we’re separated the physician group doesn’t see any of the facility fees and doesn’t really care what’s generated on that side. So we end up getting a percentage of our professional fees only.

What ends up happening is your professional fees are decreased because you’re doing procedures in an HOPD setting. We’ve asked to convert our suites into office based instead as it will generate more revenue for the physician group (and in turn us) but they said no.

So for the graduating fellows entertaining offers please figure this out before you sign with a hospital.

When I took this job it was structured as base salary or 75% of net patient revenue (pro fees) whichever was higher. Things have changed and I’ve learned more and we’re still only getting a percentage of our pro fees (nothing additional from the SOS).

This is why a lot of hospital gigs are ultimately a scam. Unless you maintain a large guaranteed base, strictly wRVU is laughable because they are literally looting what you bring in, and giving you paltry sums. Then they want you to keep seeing and doing more, and stating that "you're not bringing in enough revenue/RVUs." Couple that in with purely productivity pay, you end up finding yourself in a rut where you are working like you own the practice without any of the perks, limiting your vacation time, working lots of hours, and then attending meetings/committee meetings after work. Ultimately, if the goal was less work and more pay, how does this exactly fit into that structure? Better off owning your own practice.

Having worked for a hospital, I have seen the ugly side of it. I'm sure there are some great sides, but I'll pass. I've seen all there is.

 

[Newyorkgiants]

I don’t know what graduating fellows are finding. It seems to me that the field is so flooded (perhaps by non-ACGME interventional spine”fellowship” trained docs) that the only jobs available in half way desirable locations are medical Mgmt jobs. I’ve inquired about two jobs in the last week, one in WA and the other in CA. Both responded leading with- “ in the interest of not wasting your time.... this is a medical management job with minimal in office simple procedures (TPI, GON)”. On further investigation each facility has both anesthesiologists and PM&R doing interventions and looking for a sucker to deal with the meds and take a bullet for the team.

very slim pickings right now. I have found a number of jobs in desirable locations looking for “PMR only” which is extremely frustrating.

 

[drusso]

I don’t know what graduating fellows are finding. It seems to me that the field is so flooded (perhaps by non-ACGME interventional spine”fellowship” trained docs) that the only jobs available in half way desirable locations are medical Mgmt jobs. I’ve inquired about two jobs in the last week, one in WA and the other in CA. Both responded leading with- “ in the interest of not wasting your time.... this is a medical management job with minimal in office simple procedures (TPI, GON)”. On further investigation each facility has both anesthesiologists and PM&R doing interventions and looking for a sucker to deal with the meds and take a bullet for the team.

This is the whole West Coast.

 

[drusso]

This is why a lot of hospital gigs are ultimately a scam. Unless you maintain a large guaranteed base, strictly wRVU is laughable because they are literally looting what you bring in, and giving you paltry sums. Then they want you to keep seeing and doing more, and stating that "you're not bringing in enough revenue/RVUs." Couple that in with purely productivity pay, you end up finding yourself in a rut where you are working like you own the practice without any of the perks, limiting your vacation time, working lots of hours, and then attending meetings/committee meetings after work. Ultimately, if the goal was less work and more pay, how does this exactly fit into that structure? Better off owning your own practice.

Having worked for a hospital, I have seen the ugly side of it. I'm sure there are some great sides, but I'll pass. I've seen all there is.

You need to speak more freely about this. This is the dirty underbelly that new grads and job seekers are not seeing. Let the light shine in!

 

[NJPAIN]

Perhaps this ridiculous over abundance of pain, sports and spine, whatever the eff you call yourself will spark a decrease in applicants to programs similar to what we saw in anesthesiology in the mid 90s. The number of fellows trained yearly is outrageous. Now will begin a period where either you can’t find a job or you will get paid some ridiculous salary. Same thing in anesthesiology in the 90s. Either no job or $75k starting salary. Then we had to troll Europe and Asia for residents for a few years. No American wanted to go into anesthesiology. This is what happens when you open the process to every specialty and develop alternate routes to certification. “Fellowship” programs want bodies and specialty boards want $$$. Why don’t I hear this happening in other fields??? Something is seriously wrong with us that we have let this become a free for all.