Job offer feedback: the cost of following your heart?

[lockian]

Thanks, all, for the varied perspectives and good advice. Still not sure what I am going to do. Maybe I'll pick out of a hat or something.

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[Sushirolls]

You have to answer some of these questions for yourself. Do you want to chase money right now? If so, go do it. If you are open to settling in one of these places permanently and really dropping anchor for your long term life, then definitely choose the more stable, better contract.

There are numerous things that can ruin a job. Bad corporate, bad admin, bad manger, bad med director. Bad support staff. Bad payment for the work you do. Too little vacation. Bad benefits. Cheap low quality health insurance. Bad mental health laws at the state level. High income taxes, high property taxes, etc. Too much crime, to where you really need to live in the 'good side of town' (there are places in the country where such divisions are more aesthetic than functional).

Personally, I'm a 90 min consult kind of person.

Are the people in the group benzo prescribers? It's a pain when you do their vacation coverage because you will be swimming thru a surge of benzo refills.

Do your immigrant refugees need interpreters? Those visits will reduce your productivity, and that means less wRVUs.

Do you have to supervise or teach or cover for ARNPs?

All jobs will tell you their RVU/productivity is easily attainable. You should ask the others in the group to show you their data and prove it. Or have the med dir show you the de-identified RVU data for the group to see for yourself. If you share some of the contract RVU numbers here, posters can further educate on what's reasonable or not. Its okay to be blunt and say, "hey, I know you guys are seeing its easy to obtain, but I'd like some real data to feel more reassured." There are jobs where its really not obtainable unless you work far harder than originally expected just to meet the magical number, and some of these places have no qualms about chewing up and spitting out fresh, young, naive grads like yourself.

What's the policy on discharging patients? Do you have the ability to do so at your discretion or does your group have an admin heavy where only the chief medical officer can authorize such a thing?

How many meetings are there that you are required and obligated to attend per week or month? That is uncompensated time, and something to also consider if living in the wRVU world.

What EMR are you working with? EMR is deal breaker for some people if its a bad one.

You might not need to negotiate pay, but we don't know if you don't tell us. How much vacation sick etc days are there? How much notice do they need before you can schedule a vacation? Is there non-compete clauses? Life changes and you may want to stay, but the job turns for the worst, its nice to have the out of being able to open your own practice.

Just because people have been there a long time doesn't mean that's a good thing. It could be they haven't had enough ambition to look elsewhere, or their family is anchored into the schools and their spouse too, and they can't uproot - so they merely tolerate things. Or they are just too old and burned out enough that they have stayed, the light of retirement seems closer then tedium of changing, and their jaded nature assumes all places are equally as bad and simply stay with the devil they know. People will often put on their smile face with new applicants because they want help with the work load, and its less likely they are TRULY happy.

In summary, leave your emotions at the door. This is business, and negotiate the best deal for you. Search for different thread I started some time back about 'got a contract, get a lawyer.'

 

[nexus73]

How much per RVU at the first job? And do you get a bonus in the first year if you end up exceeding your RVU expectation?

 

[WisNeuro]

OP, I believe that I remember where you were looking for a job. I work at one of the big non profits in that area. PM me if you want, and I can give you some background if it's for a job in my area. Hint, we're the one going through the merger.

 

[dl2dp2]

The two jobs are very similar to each other.

15k difference is trivial enough that if you ask the first place to match it I suspect they will do it, if you prefer the group better.

Working for large multispecialty nonprofit IMO is a recipe for burn out. I rarely see people over 50 staying on at a large non academic multispecialty nonprofit who are staff physicians (i.e. not in a leadership role). People tend to exit for private work once they realize how much money were made off their head, if they are not interested in playing the corporate game. It's not a bad place to start though for a trainee.

 

[lockian]

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[Merely]

I don't mind benzos. They did let someone go for excessive stimulant prescription that others didn't feel comfortable covering, so overall it stands to reason that the approach to controlled substances is more conservative.


Yes, some of them do, but I can also be my own interpreter at times - that's part of the "special skills" I mentioned. I could ostensibly set up a niche practice where all the people of a specific background gravitate to me.


First job: Teaching/supervision is not required. Some people supervise residents, and they say it's fairly lucrative. Giving lectures is not required, and you get some extra pay if you do. Second job: no supervision or teaching.


I did talk to another new grad who was hired last year and says he's sustained it easily. That said, it's a sample size of one. I couldn't find the per-RVU numbers in any of the paperwork they gave me, so I requested those numbers, as well as de-identified data of who makes how much.


Don't know.


Don't know.


Epic and MModal for dictation. Same as residency. It has its issues, but I'm used to it.


Don't know about the first. In the second job there is extra income available if you meet certain quality metrics.

In the first job, interestingly there is NO non-compete. Moonlighting is allowed as long as it's not the exact same type of work. In the second job, there's a 5 mile non compete, but in a large urban area that only eliminates one other health system among... 5+.

I like larger multi-specialty nonprofits groups at this point because 1) more people = more coverage if you need to be gone, and less frequent call 2) easy access to patients' medical history, easy to get labs and other workup, easy to coordinate with PCPs. All important things because medical contributors to mental health and vice versa are kind of a big deal.

You don’t mind benzos? Lol

 

[lockian]

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[downwithDTB]

$15k taxed and compounded over your career is about 2 years of your full time income. That's nothing to sneeze at.

Would you rather work job a for 32 years or job b for 30? Of course the exact $/RVU and no show rate influence the value of job 1, but remember that even if you go back to them and say job b offered $15k more, if they match that number it only actually matters for year 1.

 

[lockian]

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[Merely]

Sure, that makes sense.

At the same time, I asked job b if the salary really was guaranteed and they said yes, as long as the institution's finances didn't substantially change. And who knows what the odds of that are? There's a story going around in the metro area about a health system that promised high salaries that they couldn't maintain, and then cutting everyone's pay. But no one seems to be able to tell me which health system that was. :/

I don’t understand why are we comparing 32 years vs 12 years

 

[downwithDTB]

Sorry, that was a typo! I meant 32 years vs. *30*. My simple, conservative calculation suggests that $15k would be worth about two years of work over a 30 year career.

 

[Mass Effect]

Sorry, that was a typo! I meant 32 years vs. *30*. My simple, conservative calculation suggests that $15k would be worth about two years of work over a 30 year career.

Educate me on this please. In the grand scheme of things, 15K doesn't sound like it should be a game-changer to me but I am pretty bad at financial planning. That said, if 15K is that big a deal, then we should all always take the job that pays the most.

 

[downwithDTB]

Being very, very over simplified...
Chop the 15k in half to estimate marginal tax rate in a high income taxe state. Cry. Divide into monthly payments of $625 and invest them every month for 30 years. Now we have to make big assumptions. Assuming an average interest rate of 4%, which is conservative over 30 years because I want to account for depreciation for inflation (which is partially accounted for by not increasing the contribution itself which we expect to increase)...

You end up with about $440k in the bank. if you weren't already maxing your retirement accounts, that's a lot of tax advantaged money. If you were, it's still about two years of pre-tax salary.

No single year of a $15k increase in salary will change your life but over your career, consistently earning a bit more makes huge differences. With that said, you might work more in job b than job a and actually earn less/hour, leading to a longer career in hours over fewer years (or burnout and retire early and with less money and happiness).

My point is simply that if you're making under a million/year, $15k is NOT something the sneeze at or write off, especially if it's for approximately equivalent work.

 

[Armadillos]

Personally, I think you will make your self crazy if your always looking at maximizing raw financial numbers 30 years down the road. Seems more important to figure out a specific goal and decide if your likely to meet that goal based on your income and saving plan.

So if you need the extra 15k/yr to retire with a certain level of spending by your desired age then worth contemplating, but if it just means your going to die with extra money in the bank doesn’t seem like a good reason to work a less desirable job.

 

[Merely]

Educate me on this please. In the grand scheme of things, 15K doesn't sound like it should be a game-changer to me but I am pretty bad at financial planning. That said, if 15K is that big a deal, then we should all always take the job that pays the most.

15k is not a big deal lol..it’s 15k

 

[lockian]

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[splik]

Um, update... Place B came out with their official offer documents (at time of posting they said they were going to give me an offer and gave a ballpark figure), and it's 40K more than place A.

Which begs the question, "what's wrong with this job and why are they this hungry?" Thoughts on calling one of the people I made a connection with on interview day and asking them this question in a nicer way?

Secondly, I talked to a mentor about it and he said that 15K or 40K may seem like a lot to a resident, but it isn't necessarily a lot to an attending. He ultimately told me "go where you'd rather work."

If you are interested in Place A, tell them "I am really thrilled to receive this generous offer. I really have a great vibe about working here and making this my professional home. However Place B has offered me x, which is $40k more than what you offered. As I have substantial loans to pay off*, I can't pretend this is not something I am factoring into my decision making. However, all things being equal I would truly love to join you."

*assuming this is true

Don't ask them to make a counter offer explicitly, let them bargain with themselves. Of course how much you let them do that depends on how much option B is a viable option and how willing you are to walk away from option A.

If you're lucky you can play them off one another to get yourself a good deal. Please remember that non-salary items are often more important. Think about things like health insurance, retirement, disability insurance, call coverage, vacation (how much, how easy to take), sick leave, maternity/paternity leave, professional leave, CME money, opportunities for advancement/partnership etc in organization, revenue model, opportunities for part time work, culture, support staff, how many patients will they expect you to see from day one. I would rather work for the place that will cap me at 2 new pts a day on full salary than stack me with 8 new patients each day to build up my panel from the get go.

 

[dl2dp2]

I would do what splik said and try to see if you can get them to match.

40k is significant. The core content of these jobs are very similar, so I think I'd go with job B if job A can't match it.

 

[lockian]

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[dl2dp2]

I think the major difference is that in Job B's MH department is fairly young. Their outpatient side of things is basically 1/2 a doc right now, and I'd be one of two newbies next year.

Job A, on the other hand, is well established for decades.

Idk how I feel about a new program. On the one hand, "leading the charge" is not for everyone. On the other hand, new and smaller programs can be more nimble and flexible.

These differences are way too subtle to matter in real life. Both are large nonprofit multi-specialty organizations. On a day to day level I suspect these two jobs will be very similar.

40k difference is a different story if we are talking about outpatient vs. inpatient, or academic vs. community or for-profit (i.e. partnership track) vs. non-profit etc. This is basically 40k free cash on the table for the same exact job.

 

[lockian]

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[downwithDTB]

40k per year for similar job and a contracted 40k/year vs. an RVU based "who knows" after year 1. Even if job A offers you an extra $40k for year one, that doesn't change the fact that you'd have to hit a higher RVU number the following year to equal that salary.

It's only $20k after tax if you pay tax on it and don't invest it. It might be a lot more than $40k if you tax advantage it and hold on to it until you retire or use it to pay down loans sooner if your rate is high.

 

[lockian]

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[Liquid8]

There's just something I can't put my finger on about place B that felt "icky" and it's only compounded by the overly generous offer (even though most of the staff were cool), while place A has a great reputation that precedes it. (So no, I don't think anyone's staying there simply because of inertia...).

Sometimes no amount of analysis or number crunching is going to overcome a strong gut feeling or intuition, and conversely if the analysis comes up roughly equal than it often comes down to that sense and trusting yourself. I think that it is the quality of the support staff that can make or break one's experience. If the people that handle the billing, appointments, marketing etc are all top notch, then that means I can focus on what I'm trained to do. Patients come and go and if you develop a reputation for working in a certain area word will get around. As psychiatrists we mainly practice independently although it is good to have experienced heads around to bounce ideas off.

I've only had to make this kind of choice twice - at the training level and as a consultant, and in both instances I haven't regretted my decision. In the first case I knew that I'd really dodged a bullet as nearly all their trainees quit within a year. In the latter instance the only financial benefit was a rent free period, but a few colleagues who took this option had a very difficult time. This was a relatively new place, and a lot of processes were not streamlined or done particularly well. One of the complaints I remember was that new patients seemed to be only allocated to certain certain psychiatrists, so it was essentially feast or famine dependent on how thoughtful (or thoughtless) the person allocating referrals was on the day.

Other things were more subtle. When I started I'd go out with the marketing lady to meet potential referrers, and on one visit she pointed out a poster from the other place advertising a CPD event noting that they'd missed a big opportunity as they had not named the psychiatrists presenting the talks. If the talk was on a subject with a lot of community demand, then naming of the psychiatrists would generate referrals to them and indirectly help the business, or at the very least generate a discussion amongst the referrers.

 

[Merely]

Why r we still having this conversation lol, you obviously have a job you like much more so go do that one, good luck

 

[lockian]

Why r we still having this conversation lol, you obviously have a job you like much more so go do that one, good luck

I'm not so sure I like it anymore. It might be too much of a challenge to work with the population at the first place, and to worry about RVU's. And whatever my financial situation, I'm still sensitive to a higher salary.