MSG/Hospital jobs

[wakaflocka88]

This is how the MSG operates when a physician retires and they hire a replacement.
Another scenarios is, they hire a new grad for 500k, the retiring doc was making (producing) 500K, it's a wash and they don't get anything except for whatever equity they have in their own building or whatever real estate purchased through the MSG. (get AR obviously)

So he could get 500K through two years by hiring me within a few months, and then me and the other partner find a 3rd (base of 200-250k).

I could also wait him out for a few years, but this is coming directly from the MSG. They are trying to stay out of it and let the two man practice decide who to hire. This is a way to protect the older doctors in the group, including non podiatry.
.
However, what this retiring doctor doesn't want to do is have a contingency (they hire me, he retires and then we hire a 3rd to basically pay for his "retirement"), he just wants a negotiated payout without the third. We could always pay him 400, and then hire another guy at 200 base with some bonus type potential, to pay the guy off over 3 years which is exactly what we would do.
You are basically paying to be a part of the MSG, with access to buying a building, profit sharing, etc.
I do think the potential is HUGE. So if the other partner split it with me it would come out as overhead from the practice and maybe 50-75k per year of lost wages. even less if we hired a third.

This sounds really convoluted and confusing to me. And also borderline sketchy too because as Feli alluded to, it doens't sound like you will own anything tangible except the possibility of a paper contract for the job? I agree with Feli and try everything he suggested for the job first.

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[hotpoddy]

Basically just buying into the MSG.
potential for large payout when I retire, own part of my building and be able to invest in their real estate
profit sharing
nothing comes out of my pocket, only as overhead out of the practice

 

[Feli]

...You are basically paying to be a part of the MSG, with access to buying a building, profit sharing, etc...

That is the wildest thing I have ever heard of. You buy a job and "access to buying" other stuff? You are seriously talking about paying 350k-400k for a job you could find many other places (or create a very good startup office on your own for that money). You are not getting shares in the MSG, you are not getting equipment, not real estate... just a job? Again, makes zero sense. I don't care if "This is how the MSG operates"... do you really want to be part of that: depending on bamboozling some new guy to finance your leaving or retiring? It doesn't make sense.

What I (or anybody, except airbud and Chuck Norris) thinks doesn't matter, though... what matters is how you view it. It is clear you are arguing for the deal to be good since you see value in it. Maybe run it by an attorney and see what they tell you? You are not going to like any of the answers you get here.

...Another scenarios is, they hire a new grad for 500k...

"Hire a new grad for $500k"??? Hmmm, most places could hire two or three for that money! Just like a lot of deals and concepts, if it doesn't even make sense at first glance, you can stop right there

...The MSG is "trying to stay out of it?" Normal groups (sometimes) have partner shares and the incoming or retiring docs buy/sell them with everything spelled clearly in contract. It is all very clearly defined. I have seen a few ortho, pod, etc groups that do have their arrangements very well defined and do convert new hires to partners within a few years. It is rare but not at all subjective.

In this case you are looking at, the DPM duo is trying a bunch of carrots on sticks to make you simply buy a job (that they are leaving). They are pressing you to remind you who controls the hiring ("let the two man practice decide who to hire"). You are getting absolutely no real tangible value - besides a job you could get for free elsewhere. Back in reality, it usually goes the other way around (new hire gets sign/relocate bonus from hosp/MSG/etc). That is all I will tell you. Best of luck.

Basically just buying into the MSG... he just wants a negotiated payout ...

So, what percentage will you own... how many shares... how many shares are outstanding.... what do shares mean... will more shares be created in the future? These things all need to be in black and white. In your case, all you keep saying is "potential" and "possibility," which won't pay your loans or your living expenses. As it stands, you are just giving the outgoing DPM(s) a humungou$$$ retirement gift... when you should be getting a sign bonus instead. It is fine to be excited about a job, but you are being bent over based on everything you have said. "Negotiated buyout"... that right there tells you it is not at all defined and simply him trying his attempt to take you for all you're worth.

Even if they do have a legit plan for shares or partnership (they don't, since it is just the DPM talking), it is normally not wise to buy into something until you've already worked there and like what you are buying, but you will make your own choices. You could try the angle of that you just want to work and you might consider buy-in down the line (but consult an attorney!).

But seriously, man... much better to learn now by dissecting the "deal" so that you would never even consider this for 2mins if you ever see a similar "offer" in the future.

 

[wakaflocka88]

Basically just buying into the MSG.
potential for large payout when I retire, own part of my building and be able to invest in their real estate
profit sharing
nothing comes out of my pocket, only as overhead out of the practice

Buying into a MSG usually works like this (not always, but usually) - you are salaried for X amount for 1.5-2 years and you go up for review by the entire MSG comittee - if you're producing and doing good, hard work - they will allow you purchase "shares" to become a partner of the group. When I say "shares," it's usually just a formality thing and it can be anywhere from a couple hundred bucks for a few shares so now that you're an official partner and can partake in profit sharing and your salary is now calculated on RVU/wRUV. Your situation above - without knowing all the details - does not like sound like you're just buying into MSG but sounds more like the pod that's leaving wants to line his pockets with some moola before really leaving.

And when you mention "nothing comes out of my pocket, only as overhead out of the practice" - it made me think of Shark Tank and Kevin O'Leary's royalty deals where it just cuts into the company's overall profit, when it turn limits your own profits for X time.

All you have to do is sit down, calculate numbers and if the bottom line is in your favor, then go for it. Don't include the potentials, what-ifs, or possibilities for your calculation. If real estate is included as stated verbatim in the contract, then include that in your calculations.

Hire a contract attorney.

 

[hotpoddy]

So another way to think about it is like this.
First 3 years, base of 200K, first 50-75k over this goes to the practice (to the guys buy-out), everything else you collect goes into your pocket (minus expenses of course). Will make 400-500 salary after all of this. I know it sounds crazy AF, but I think it works.

 

[Pronation]

So another way to think about it is like this.
First 3 years, base of 200K, first 50-75k over this goes to the practice (to the guys buy-out), everything else you collect goes into your pocket (minus expenses of course). Will make 400-500 salary after all of this. I know it sounds crazy AF, but I think it works.

Is 20 pound for the weight like 30 pounds if a guy lifts?
No gym for home, work out floor with 30, but is it for 20 like 30 lb when you no lift it to be for men, for 30 lbs instead? or half is 10 for 20 pounds?

UMM HOW i word this... ok u take 20 lbs no lifting for 30lb if guy, so divide 2 u dont sit, u get 10 but for guy it no 30, so 20 would be for guy if u werent a girl ?

 

[hotpoddy]

Is 20 pound for the weight like 30 pounds if a guy lifts?
No gym for home, work out floor with 30, but is it for 20 like 30 lb when you no lift it to be for men, for 30 lbs instead? or half is 10 for 20 pounds?

UMM HOW i word this... ok u take 20 lbs no lifting for 30lb if guy, so divide 2 u dont sit, u get 10 but for guy it no 30, so 20 would be for guy if u werent a girl ?

Yeap…just like that buddy.
If ya worded it like it was a pp job it would be the golden goose. Well of PP jobs at least.
Prove me wrong.
Pretty sure no one here is making over 450?

 

[DYK343]

Pretty sure no one here is making over 450?

Take the job if it feels right for you. But there are jobs out there that pay well. Thats what were trying to tell you. Those are hard to find for newly grads but they do exist.

Seems like people are being a bit rough on you.

But the contract is bizarre. Very bizarre. Thats why youre getting the responses youre getting. Because its not the norm in any DPM/MD/DO/DDS/medical field contract. Sounds a little bit like a pyramid scheme.

If it works exactly like you want sure it could be a decent deal in years to come and is better than taking a crappy PP job in florida.

But what if you buy in and then decide its a terrible fit? Thats what I would be really worried about. Youre stuck. Feli just said above he changed jobs twice recently.

I have been thinking about leaving mine as of recently (im not but thought has crossed my mind due to some BS that has been popping up).

Get a reputable health care attorney to read the contract and guide you. It will be worth the 1k or whatever they cost to go through the document. It sounds like a lot now but..... could save you a massive buy in

 

[dtrack22]

first 50-75k over this goes to the practice (to the guys buy-out

Pretty sure no one here is making over 450?

Obviously not…actually…never mind

But it doesn’t sound like you actually will be either 😂

 

[dtrack22]

you are salaried for X amount for 1.5-2 years and you go up for review by the entire MSG comittee - if you're producing and doing good, hard work - they will allow you purchase "shares" to become a partner of the group. When I say "shares," it's usually just a formality thing and it can be anywhere from a couple hundred bucks for a few shares so now that you're an official partner and can partake in profit sharing and your salary is now calculated on RVU/wRUV.

Yeah, pretty much every MSG set up with partnership opportunity that I’ve seen has looked like the above.

The convoluted contract described by hotpoddy is clearly a retirement scheme/gift being orchestrated by the retiring podiatrist. The fact that none of this is supported by or run through the real doctors (MD/DO) who are partners/owners within this MSG should make that clear

 

[air bud]

Sounds like some employed pods figured out a way to screw over a new pod without being their boss

 

[Feli]

Sounds like some employed pods figured out a way to screw over a new pod without being their boss

 

[wakaflocka88]

Yeap…just like that buddy.
If ya worded it like it was a pp job it would be the golden goose. Well of PP jobs at least.
Prove me wrong.
Pretty sure no one here is making over 450?

sorry dude your prospect will not net you 450 anytime soon. The old pod siphoning 75k from your “overhead” is no different than you giving him the 75k. It doesn’t matter how he words it or how it’s schemed- the numbers do not lie.

If you do pursue please have an attorney comb over this so there isn’t some tiny fine print saying the old pod gets a life time perpetual payment as part of your overhead

 

[hotpoddy]

Haha I agree with everyones skepticism.
I have discussed this with the head of the MSG. This is the same type buy out scenario for the other physicians within the organization, DO, MD, OD whatever
I also went to school with the other guy I would be partnering with, he has been with the group two years and everything is legit.
Will definitely have an attorney take a look at the contract

 

[Spotinho]

Thank you for the replies, I reviewed the threads out there. I had a few follow up thoughts...if anyone can chime in.

I started out of residency in an ortho group and as many posters have said over and over again - they want to know how you can produce and help the group grow. Sure, your training matters, but good training will help lend to better confidence minus the ego when it comes to that stage of discussions. I have done almost every forefoot/midfoot/rearfoot procedure I was trained to do in the 1.5 years I've been out.

Edit - just also want to add this: majority of ortho has no clue what podiatry programs and residency consists of. Zero, nothing. You can go to the best program that is well known within our profession but the outside world has no idea what that means or entails. Like I said above, good training lends to confidence which in turn shows in how you carry yourself, your knowledge and how you perform. You can go to JPS UPMC Kaiser Yale Harvard etc etc but the name will not get you an offer in hand

So when you hypothetically get into these stage of discussions with msg/ortho/hospital in how you can help them grow and make them money... what are they looking for to believe what you're saying, trust you are capable, and know you are the right person for the position? Are they looking for a case log of numbers? If not, what? Which brings me to the question what is more important then, quantity vs quality of numbers? I would assume numbers would just look better in paper and lead to a better chance in getting one of those jobs.

Quantity: meaning high volume of cases but doing 1/3 skin to skin
Quality: perhaps doing a 1/2 of the cases from above but doing virtually all of them skin to skin

My advice is to focus on being the best version of yourself no matter where you end up. A strong program will NOT guarantee you to be a strong podiatrist. What you are willing to put in is what you will get out of your 3 years. I did not pursue a fellowship.

Similarly, wouldn't a fellowship make you look better on paper and increase your chances of landing one of these jobs?

I understand there is no guarantees with anything as you mentioned, just mostly trying to get to the nitty gritty to put myself in the best situation once that time comes. Thank you for sharing your experiences and thoughts on the matter.

 

[CutsWithFury]

Similarly, wouldn't a fellowship make you look better on paper and increase your chances of landing one of these jobs?

I hate this mindset which has now successfully been ingrained into the profession. I am not fellowship trained. I completed strong residency program where I did thousands of procedures. I have completed thousands more in practice over 5 years. I've built a hospital based practice from nothing during that time. I produce 1000+ RVUs a month. I am board certified. I would consider my career "successful".

I look at new job postings from time to time. Biggest change I have seen in the job market is that the hospital wants a "Fellowship trained" podiatrist. They probably don't even care but they assume they need one because the profession of podiatry has made it so. I don't think any of the new fellowship trained grads are as good as me. They don't have my experience with building a practice, billing and they are not board certified. So I find it peculiar that someone like myself who has proven track record can't even get an interview for these hospital positions.

It has created a precedent that we can't really ignore anymore in my opinion. I think there are handful of fellowship programs that actually make the person a better surgeon. The others are just cheap labor or they create false confidence in one's own abilities. It also makes getting a job even harder for the majority of the profession's resident graduates who are NOT fellowship trained.

 

[wakaflocka88]

Thank you for the replies, I reviewed the threads out there. I had a few follow up thoughts...if anyone can chime in.



So when you hypothetically get into these stage of discussions with msg/ortho/hospital in how you can help them grow and make them money... what are they looking for to believe what you're saying, trust you are capable, and know you are the right person for the position? Are they looking for a case log of numbers? If not, what? Which brings me to the question what is more important then, quantity vs quality of numbers? I would assume numbers would just look better in paper and lead to a better chance in getting one of those jobs.

Quantity: meaning high volume of cases but doing 1/3 skin to skin
Quality: perhaps doing a 1/2 of the cases from above but doing virtually all of them skin to skin


Similarly, wouldn't a fellowship make you look better on paper and increase your chances of landing one of these jobs?

I understand there is no guarantees with anything as you mentioned, just mostly trying to get to the nitty gritty to put myself in the best situation once that time comes. Thank you for sharing your experiences and thoughts on the matter.

I would listen to what Cuts said below me. I’m 1.5 year out and I can guarantee a fellowship would not have “prepared” me as well as real world is. My residency was already adequate in both clinical and surgical exposure. A fellowship will not produce what you think it may. Again, I personally know of friends and colleagues whom finished residency only to land a PP run of the mill job where I’m pretty sure they are not doing anything close to what their fellowship entailed.

Your questions and scenarios are what-ifs. Worry more when you have completed a portion of your residency first then you’ll better understand what it’s like. Just like Cuts said above, my residency program was balanced in volume for forefoot/rear foot/trauma/limb salvage with a lot of cut time and also a lot of my own personal clinic seeing and working everything up, so I did not feel I needed to pursue a fellowship. Would a fellowship made me better? I can’t predict the future.

This is only ONE aspect of being a prospective candidate for these jobs. Your personality, what others have to say about you, your work ethic, morale compass etc etc also dictates a lot too.

Does this make sense? It’s not easy conveying this information via words alone. You’ll figure it out - for better or for worse but you’ll have to learn along the way. We all did.

 

[NobodyDPM]

I hate this mindset which has now successfully been ingrained into the profession. I am not fellowship trained. I completed strong residency program where I did thousands of procedures. I have completed thousands more in practice over 5 years. I've built a hospital based practice from nothing during that time. I produce 1000+ RVUs a month. I am board certified. I would consider my career "successful".

I look at new job postings from time to time. Biggest change I have seen in the job market is that the hospital wants a "Fellowship trained" podiatrist. They probably don't even care but they assume they need one because the profession of podiatry has made it so. I don't think any of the new fellowship trained grads are as good as me. They don't have my experience with building a practice, billing and they are not board certified. So I find it peculiar that someone like myself who has proven track record can't even get an interview for these hospital positions.

It has created a precedent that we can't really ignore anymore in my opinion. I think there are handful of fellowship programs that actually make the person a better surgeon. The others are just cheap labor or they create false confidence in one's own abilities. It also makes getting a job even harder for the majority of the profession's resident graduates who are NOT fellowship trained.

First bold:
Not sure I agree. Only in academic circles. Sure you can use that as a springboard when interviewing for a position, but chances are, if it's not a Podiatrist looking at your CV, they have no idea what that is or what it means.

Second bold:
Not sure I agree with this either. My take is that Fellowships are either for people who just don't want to start working yet, or for those who aren't comfortable with their skills and still need someone to oversee their work. Which fellowships do you think do this?

 

[Shiyuan]

Although N=1 with this scenario:

I had a colleague land a good VA gig... my colleague was interviewed by allopathic docs and the docs respected their podiatric wound care fellowship (1 year fellowship).

So a fellowship can certainly help...

But I tend to agree more with Cuts on this one.

 

[CutsWithFury]

First bold:
Not sure I agree. Only in academic circles. Sure you can use that as a springboard when interviewing for a position, but chances are, if it's not a Podiatrist looking at your CV, they have no idea what that is or what it means.

Second bold:
Not sure I agree with this either. My take is that Fellowships are either for people who just don't want to start working yet, or for those who aren't comfortable with their skills and still need someone to oversee their work. Which fellowships do you think do this?

Disagree on both statements. Fellowship training essentially means better trained in any orthopedic circle. Every orthopedic specialist has fellowship training. They see fellowship and they assume the podiatrist has good training whether that is true or not.

Have you been involved in the fellowship interview process or even gone through fellowship interviews? I have. I thought I needed one. I wanted one but did not get one. I interviewed at only a handful that historically are incredibly strong. Since that time there have been numerous others that have opened which are simply an extra year of residency at some programs or do not provide cases that are significantly different from what the candidate was already doing in residency or SHOULD HAVE BEEN DOING in residency. Just like there is a spectrum of residency training there is wide spectrum of fellowship training.

My biggest concern is now fellowship trained podiatrists are deemed desirable when people like myself who have had a relatively productive/successful career are not even considered. I don't think a fellowship trained podiatrist fresh out of fellowship is a superior clinician or surgeon than someone who did a solid to great residency program and who has logged thousands of procedures in practice/ has 5+ years of experience. It's not an accurate assumption. Then we are seeing some fellowship grads graduating from historically strong programs who have also have no real practice experience and are not board certified being consultants for certain companies. It is highly questionable. Especially since these individuals have no real practice track record of success using the product outside of implanting it in their fellowship director's patients. It is a scary world out there.

Then raises the question...what happens to all the other resident graduates who did not do a fellowship? How do they compete with these fellowship trained DPMs that are increasing by the year because more "fellowship" programs are opening up? How do they compete with someone like myself who has significant practice experience? It's a scary world out there for new grads.

 

[air bud]

First bold:
Not sure I agree. Only in academic circles. Sure you can use that as a springboard when interviewing for a position, but chances are, if it's not a Podiatrist looking at your CV, they have no idea what that is or what it means.

Second bold:
Not sure I agree with this either. My take is that Fellowships are either for people who just don't want to start working yet, or for those who aren't comfortable with their skills and still need someone to oversee their work. Which fellowships do you think do this?

way off on the second. Then why do you get multiple West Penn graduates year after year doing fellowships? Catz stopped learning how to teach? They just pick the wrong residents? Sorry nobody you are too far out to understand this one. It is being done 90 percent for resume buildine or false hope/belief in the system.

 

[josebiwasabi]

Are hospitals/MSG/Ortho groups really comparing new fellowship grad vs 5 years of practice experience w/ board certification?

In my experience as someone who did a fellowship and was applying for jobs, although the fellowship was a plus compared to a new grad out of residency, it did not put me ahead of someone who was already established and 5 years into their career.

If they do go for the fellowship trained applicant, it's not because they think that they are a better doctor than the one with more experience. I think from a $$ perspective what the bean counters are thinking is that they can pay a new grad (fellowship trained or not) a lower base salary compared to someone who is going to demand greater pay due to their years of experience. And they get to advertise that all of their surgeons are fellowship trained (especially true for ortho groups).

I agree with the overall sentiment that there are a lot of fluff fellowship programs being established out there. I was pretty selective with where I applied/interviewed at because I didn't want to waste the year as an underpaid attending.

 

[NobodyDPM]

way off on the second. Then why do you get multiple West Penn graduates year after year doing fellowships? Catz stopped learning how to teach? They just pick the wrong residents? Sorry nobody you are too far out to understand this one. It is being done 90 percent for resume buildine or false hope/belief in the system.

Okay. Fair enough.

 

[NobodyDPM]

Disagree on both statements. Fellowship training essentially means better trained in any orthopedic circle. Every orthopedic specialist has fellowship training. They see fellowship and they assume the podiatrist has good training whether that is true or not.

Have you been involved in the fellowship interview process or even gone through fellowship interviews? I have. I thought I needed one. I wanted one but did not get one. I interviewed at only a handful that historically are incredibly strong. Since that time there have been numerous others that have opened which are simply an extra year of residency at some programs or do not provide cases that are significantly different from what the candidate was already doing in residency or SHOULD HAVE BEEN DOING in residency. Just like there is a spectrum of residency training there is wide spectrum of fellowship training.

My biggest concern is now fellowship trained podiatrists are deemed desirable when people like myself who have had a relatively productive/successful career are not even considered. I don't think a fellowship trained podiatrist fresh out of fellowship is a superior clinician or surgeon than someone who did a solid to great residency program and who has logged thousands of procedures in practice/ has 5+ years of experience. It's not an accurate assumption. Then we are seeing some fellowship grads graduating from historically strong programs who have also have no real practice experience and are not board certified being consultants for certain companies. It is highly questionable. Especially since these individuals have no real practice track record of success using the product outside of implanting it in their fellowship director's patients. It is a scary world out there.

Then raises the question...what happens to all the other resident graduates who did not do a fellowship? How do they compete with these fellowship trained DPMs that are increasing by the year because more "fellowship" programs are opening up? How do they compete with someone like myself who has significant practice experience? It's a scary world out there for new grads.

I understand. And agree that maybe I've been out to long to "get it".

That being said, we are talking about the minority of jobs available out there. If you only want to do a fellowship because you think it will land you a cushy Ortho practice job, and it doesn't, then what? Did you waste a year of your life? My take is that yes, you did.

As it's been said here before, no one out there really cares where or how you trained. If you did your residency and get board qualified and then certified, a fellowship really adds nothing to the stew. I personally know some colleagues that did Fellowships when they first became a thing thinking it would give them a leg up, and it did exactly nothing for them. Again, I concede that things may have changed and I may be out of the loop in this regard, but I've also been training residents for 20+ years now.

 

[DYK343]

Disagree on both statements. Fellowship training essentially means better trained in any orthopedic circle. Every orthopedic specialist has fellowship training. They see fellowship and they assume the podiatrist has good training whether that is true or not.

Have you been involved in the fellowship interview process or even gone through fellowship interviews? I have. I thought I needed one. I wanted one but did not get one. I interviewed at only a handful that historically are incredibly strong. Since that time there have been numerous others that have opened which are simply an extra year of residency at some programs or do not provide cases that are significantly different from what the candidate was already doing in residency or SHOULD HAVE BEEN DOING in residency. Just like there is a spectrum of residency training there is wide spectrum of fellowship training.

My biggest concern is now fellowship trained podiatrists are deemed desirable when people like myself who have had a relatively productive/successful career are not even considered. I don't think a fellowship trained podiatrist fresh out of fellowship is a superior clinician or surgeon than someone who did a solid to great residency program and who has logged thousands of procedures in practice/ has 5+ years of experience. It's not an accurate assumption. Then we are seeing some fellowship grads graduating from historically strong programs who have also have no real practice experience and are not board certified being consultants for certain companies. It is highly questionable. Especially since these individuals have no real practice track record of success using the product outside of implanting it in their fellowship director's patients. It is a scary world out there.

Then raises the question...what happens to all the other resident graduates who did not do a fellowship? How do they compete with these fellowship trained DPMs that are increasing by the year because more "fellowship" programs are opening up? How do they compete with someone like myself who has significant practice experience? It's a scary world out there for new grads.

Start a fellowship then put fellowship director on your CV.
Problem solved!

 

[air bud]

Disagree on both statements. Fellowship training essentially means better trained in any orthopedic circle. Every orthopedic specialist has fellowship training. They see fellowship and they assume the podiatrist has good training whether that is true or not.

Have you been involved in the fellowship interview process or even gone through fellowship interviews? I have. I thought I needed one. I wanted one but did not get one. I interviewed at only a handful that historically are incredibly strong. Since that time there have been numerous others that have opened which are simply an extra year of residency at some programs or do not provide cases that are significantly different from what the candidate was already doing in residency or SHOULD HAVE BEEN DOING in residency. Just like there is a spectrum of residency training there is wide spectrum of fellowship training.

My biggest concern is now fellowship trained podiatrists are deemed desirable when people like myself who have had a relatively productive/successful career are not even considered. I don't think a fellowship trained podiatrist fresh out of fellowship is a superior clinician or surgeon than someone who did a solid to great residency program and who has logged thousands of procedures in practice/ has 5+ years of experience. It's not an accurate assumption. Then we are seeing some fellowship grads graduating from historically strong programs who have also have no real practice experience and are not board certified being consultants for certain companies. It is highly questionable. Especially since these individuals have no real practice track record of success using the product outside of implanting it in their fellowship director's patients. It is a scary world out there.

Then raises the question...what happens to all the other resident graduates who did not do a fellowship? How do they compete with these fellowship trained DPMs that are increasing by the year because more "fellowship" programs are opening up? How do they compete with someone like myself who has significant practice experience? It's a scary world out there for new grads.

Huh, I wonder who you are talking about...

 

[wakaflocka88]

Perused the ACFAS fellowship page and there's the University Hospitals fellowship has a 2(two!) year position. What the hell do you do for an extra 2 years? One foot only per year of your 2 year fellowship? Scary to think that after 3 years of training, this is an option....

Again I personally know of fellowship trained pods that are in run of the mill PP jobs. The best residency program or the best fellowship program or combination of the two will NOT guarantee you what you think you may be entitled to. If interviewing for a competitive job, a fresh fellow versus an experienced pod 5+ years out - trust me, the department/panel will know - DPM and MD alike.

 

[Scrantonicity]

Perused the ACFAS fellowship page and there's the University Hospitals fellowship has a 2(two!) year position. What the hell do you do for an extra 2 years? One foot only per year of your 2 year fellowship? Scary to think that after 3 years of training, this is an option....

Again I personally know of fellowship trained pods that are in run of the mill PP jobs. The best residency program or the best fellowship program or combination of the two will NOT guarantee you what you think you may be entitled to. If interviewing for a competitive job, a fresh fellow versus an experienced pod 5+ years out - trust me, the department/panel will know - DPM and MD alike.

That is absolutely insane to think about. Is this really the direction things are going now? It's this obsession with parity that has taken us here...

 

[air bud]

Lol I love that there is a large private practice group in Ohio that has it's own fellowship.

"Ok partners, how can we figure out how to pay an associate less than an associate?

"Ok hear me out. Instead of giving an associate a crappy contract then dealing with the headache of them leaving after a year, we just give them a flat fee and 1 year contract and call it a fellowship!"

"Brilliant idea ol'chap"

"A fellowship in Life!"

 

[wakaflocka88]

That is absolutely insane to think about. Is this really the direction things are going now? It's this obsession with parity that has taken us here...

I can understand if a fellowship leads one to the promise land, but alas, how many new fellows do we see year after year in a predatory PP group. All we see on IG are these fellows doing fancy nerve transplanation cases or whatever orthoplastic stuff they're touting but in reality, it just ain't happening afterwards.

 

[Pronation]

I can understand if a fellowship leads one to the promise land, but alas, how many new fellows do we see year after year in a predatory PP group. All we see on IG are these fellows doing fancy nerve transplanation cases or whatever orthoplastic stuff they're touting but in reality, it just ain't happening afterwards.

It was about parity at first but, just like everything else that's abused in this profession, it's now a way to milk out even cheaper labor for these shady characters.

 

[Weirdy]

That is absolutely insane to think about. Is this really the direction things are going now? It's this obsession with parity that has taken us here...

makes me depressed and i'm not even done with residency yet

 

[air bud]

makes me depressed and i'm not even done with residency yet

Don't worry, just do a fellowship and then you have an extra year to get over it before you have to figure out the real world.

 

[NobodyDPM]

makes me depressed and i'm not even done with residency yet

Like everything else on the internet, take this stuff with a HUGE grain of salt. If not a boulder sized piece of salt. Do your thing and be the best you can be. The rest will fall into place. Do you. That's it.

 

[Feli]

...So when you hypothetically get into these stage of discussions with msg/ortho/hospital in how you can help them grow and make them money... what are they looking for to believe what you're saying, trust you are capable, and know you are the right person for the position? Are they looking for a case log of numbers? If not, what? Which brings me to the question what is more important then, quantity vs quality of numbers? ...


...Similarly, wouldn't a fellowship make you look better on paper and increase your chances of landing one of these jobs?

I understand there is no guarantees with anything as you mentioned, just mostly trying to get to the nitty gritty to put myself in the best situation once that time comes. Thank you for sharing your experiences and thoughts on the matter.

Most groups simply want a likable person with adequate training (board qual/cert, etc). Their primary want is someone who their patients and staff will like... but that person also needs to get on insurance plans and hospitals and such without restriction. You want to pimp your boards and your many many offerings for the patients, based on your training.It is usually best not to bring up money(just talk about the many surgery procedures you can do, imaging you order, your efficiency in office, etc), but you can follow their lead if they ask about billing (they will usually just ask "how many patients do you like to see in a typical day?").

If it's a DPM interviewing and the group does a lot of big cases (any ortho group and some pod/hosp/MSGs) or it's a pod/hosp/MSG group that needs someone to funnel that stuff to, then the logs and ability to do higher complexity will matter more. You want to be competitive for all types of jobs, not just forefoot and wound care... so again, you need good residency. There will be hospital or ortho jobs where the DPMs don't set foot in the OR (just injects and orthotics and nonsense) and there will be PP associate jobs where you will need to do ankles and Charcot monthly or even weekly. Don't fall into the mindset that PP is bad and hosp/ortho/MSG is good automatically. It is getting fairly common for the groups - all kinds - to need the complex/RRA from their new hire and/or to pay more for it, but most groups still just want someone they like and who meet the basic reqs of being and avg or better DPM (boards, 3yr, no major malfunctions, etc). You will find the whooole spectrum once you browse jobs: non-op, wound care, forefoot, RRA, trauma, etc etc. Good training and passing boards keeps all of those doors open.

The case logs and diversity/complexity are more just for your own personal growth. These are the skills for probably the next 20-40yrs of your life. You want to be VERY solid on F&A diagnostics and surgery. You need a lot of cases and good teachers to get to that point. The logs can also help with privileging, but they can be inflated... yet real skill once the OR timeout begins is ultimately on you.

Fellowship is your choice. You would mention it in interviews if you did one, and if you didn't do one, you just say how many cases you did in residency and promote your residency's name/history/alumni/etc as needed (if it had any of those). As was discussed, fellowship is a bit superfluous if you do a quality residency. If you can't get a good residency, then it's a consideration... but if I were screening CVs, I would take somebody who trained DMC no fellowship all day over an applicant with Miami VA and then Amita fellowship (but the DMC grad would probably want more $ and have better offers anyways, lol). Again, the comical thing is that the best fellowships only tend to take people who did the best residencies... yet those best residency grads don't need a fellowship. Average and crummy fellowships take avg/crummy residency grads... who will be avg/crummy even with the extra year. Head-scratcher for sure.

Good luck

 

[Pronation]

and there will be PP associate jobs where you will need to do ankles and Charcot monthly or even weekly. Don't fall into the mindset that PP is bad and hosp/ortho/MSG is good automatically. It is getting fairly common for the groups - all kinds - to need the complex/RRA from their new hire and/or to pay more for it

Ah, but there's a catch... you'll be doing all these fancy Charcot recons and TARs with your fancy training at a PP job all while still making $100k (plus bonus of 15% after 3.5 million collected, so total take home is... $100k...). So, sure, this specific PP gig might be good for getting your numbers for boards, but you'll still be used and abused in terms of compensation.

 

[heybrother]

Ah, but there's a catch... you'll be doing all these fancy Charcot recons and TARs with your fancy training at a PP job all while still making $100k (plus bonus of 15% after 3.5 million collected, so total take home is... $100k...). So, sure, this specific PP gig might be good for getting your numbers for boards, but you'll still be used and abused in terms of compensation.

Even if you have a "reasonable" individual PP contract the real issue will be the insurance contract. My best contract for a TAR would be BCBS at 190% of Medicare and it would therefore pay $1800 for a 27702. Presumably other people have better contracts than me. The heart of what I'm saying though is there is no magic huge lump of money for surgery unless you negotiate it or the patient pays cash. If you go PP and think I'm going to do $10,000 TARs - that isn't how it will work. Meanwhile, on a similar BCBS fee structure - $2100 for a 1st MPJ fusion and 4 hammertoes.

Final fun thought. Trying to fight insurance contracts - we're not fighting the 190% BCBS plan for 200%. We're targeting the 80% United plan ($760 for a 27702, hahaha). Maybe that's the mistake. Maybe our goal should just be to make the better contracts even better.

 

[Pronation]

Even if you have a "reasonable" individual PP contract the real issue will be the insurance contract. My best contract for a TAR would be BCBS at 190% of Medicare and it would therefore pay $1800 for a 27702. Presumably other people have better contracts than me. The heart of what I'm saying though is there is no magic huge lump of money for surgery unless you negotiate it or the patient pays cash. If you go PP and think I'm going to do $10,000 TARs - that isn't how it will work. Meanwhile, on a similar BCBS fee structure - $2100 for a 1st MPJ fusion and 4 hammertoes.

Final fun thought. Trying to fight insurance contracts - we're not fighting the 190% BCBS plan for 200%. We're targeting the 80% United plan ($760 for a 27702, hahaha). Maybe that's the mistake. Maybe our goal should just be to make the better contracts even better.

Great point and for those who are not hospital employed with RVUs, this is the perk of being part of a large MSG/ortho group (not large PP group, read: those are associate mills). I don't believe anyone in the group I'm with accepts any commercial insurances that reimburse less than Medicare.

You also bring up a good point about the reality of non RVU reimbursement as far as bigger surgeries and their complications vs these smaller forefoot surgeries.

 

[CutsWithFury]

I can understand if a fellowship leads one to the promise land, but alas, how many new fellows do we see year after year in a predatory PP group. All we see on IG are these fellows doing fancy nerve transplanation cases or whatever orthoplastic stuff they're touting but in reality, it just ain't happening afterwards.

100% accurate. The expectations vs reality are not being set. It is on the profession but it is also on the individual pursuing this training. Some candidates are buying into the facade. They think they will be doing these cases on a frequent basis in practice which is not reality. I do a lot of limb salvage and needed to think about a muscle flap in probably 1-2% of cases. If you are on top of these patients it never gets to that.

 

[NobodyDPM]

Even if you have a "reasonable" individual PP contract the real issue will be the insurance contract. My best contract for a TAR would be BCBS at 190% of Medicare and it would therefore pay $1800 for a 27702. Presumably other people have better contracts than me. The heart of what I'm saying though is there is no magic huge lump of money for surgery unless you negotiate it or the patient pays cash. If you go PP and think I'm going to do $10,000 TARs - that isn't how it will work. Meanwhile, on a similar BCBS fee structure - $2100 for a 1st MPJ fusion and 4 hammertoes.

Final fun thought. Trying to fight insurance contracts - we're not fighting the 190% BCBS plan for 200%. We're targeting the 80% United plan ($760 for a 27702, hahaha). Maybe that's the mistake. Maybe our goal should just be to make the better contracts even better.

Bold mine. For the time invested, that's awful...

 

[air bud]

100% accurate. The expectations vs reality are not being set. It is on the profession but it is also on the individual pursuing this training. Some candidates are buying into the facade. They think they will be doing these cases on a frequent basis in practice which is not reality. I do a lot of limb salvage and needed to think about a muscle flap in probably 1-2% of cases. If you are on top of these patients it never gets to that.

Have told this story before Have a friend who did what is considered the top 1 to 3 fellowships. Took a crappy PP job coming out in a city with no ties to. Hated it. BTW did ZERO Tars in 2 years. Now in a great small resort town. Lots of other private pods. Bought a dude out. Very good situation, he is doing well and enjoying life. Has done I think 1 TAR now 4 years out. Often states would much rather knock out a forefoot slam on a private insurance patient than do a TAR on a Medicare patient.

 

[msuDPM]

Have told this story before Have a friend who did what is considered the top 1 to 3 fellowships. Took a crappy PP job coming out in a city with no ties to. Hated it. BTW did ZERO Tars in 2 years. Now in a great small resort town. Lots of other private pods. Bought a dude out. Very good situation, he is doing well and enjoying life. Has done I think 1 TAR now 4 years out. Often states would much rather knock out a forefoot slam on a private insurance patient than do a TAR on a Medicare patient.

Not sure if we have same friend or if situation is all to common. Haha

 

[NobodyDPM]

Have told this story before Have a friend who did what is considered the top 1 to 3 fellowships. Took a crappy PP job coming out in a city with no ties to. Hated it. BTW did ZERO Tars in 2 years. Now in a great small resort town. Lots of other private pods. Bought a dude out. Very good situation, he is doing well and enjoying life. Has done I think 1 TAR now 4 years out. Often states would much rather knock out a forefoot slam on a private insurance patient than do a TAR on a Medicare patient.

1 TAR in 4 years? Hmmm...

 

[DYK343]

I would take an easy FF slam over a flatfoot or any more involved case anyday.
Same pay less headach.
I still take on anything that comes my way but I could see myself cutting back soon on "the big stuff"

 

[Spotinho]

Thanks everyone, once again I appreciate the feedback. I think I get the picture.

As follow up question while we are in this topic...

Why are msg/ortho/hospital podiatrists significantly higher compensated than a podiatrist who is not in one of these setups? Assuming location is the same and we are not talking about a PP owner with a well-oiled practice seeing 100+ patients that took 10+ years to build. Is it because the msg/ortho/hospital is able to negotiate higher percentages of reimbursements? Hence the podiatrist can take advantage of these contracts and get reimbursed at higher percentages for everything they do from clinic to the operating room? If this is the case are the reimbursement percentages the same an ortho F&A would get paid if they were doing the same clinic procedures and surgical cases in one of these setups or is it still an inferior reimbursement percentage than an ortho F&A would get however still superior to podiatrists who are not in these setups?

-Or-

Is it the fact that msg/ortho/hospital are more selective with which insurers they take? Which intuitively does not make sense to me as you'd think hospitals will take most if not all insurances and I don't know personally but I'm guessing msg/ortho groups that take the lower-end insurances are still making far and beyond what your typically quoted here on SDN average podiatrist makes, 120-150k.

I'd really appreciate some feedback. Thank you.

 

[Pronation]

Thanks everyone, once again I appreciate the feedback. I think I get the picture.

As follow up question while we are in this topic...

Why are msg/ortho/hospital podiatrists significantly higher compensated than a podiatrist who is not in one of these setups? Assuming location is the same and we are not talking about a PP owner with a well-oiled practice seeing 100+ patients that took 10+ years to build. Is it because the msg/ortho/hospital is able to negotiate higher percentages of reimbursements? Hence the podiatrist can take advantage of these contracts and get reimbursed at higher percentages for everything they do from clinic to the operating room? If this is the case are the reimbursement percentages the same an ortho F&A would get paid if they were doing the same clinic procedures and surgical cases in one of these setups or is it still an inferior reimbursement percentage than an ortho F&A would get however still superior to podiatrists who are not in these setups?

-Or-

Is it the fact that msg/ortho/hospital are more selective with which insurers they take? Which intuitively does not make sense to me as you'd think hospitals will take most if not all insurances and I don't know personally but I'm guessing msg/ortho groups that take the lower-end insurances are still making far and beyond what your typically quoted here on SDN average podiatrist makes, 120-150k.

I'd really appreciate some feedback. Thank you.

It's simply because private practice owners are incredibly greedy and selfish. Probably has something to do with their sense of "seniority" and how they had to "pave the way" etc.

 

[blasthardcheese]

Thanks everyone, once again I appreciate the feedback. I think I get the picture.

As follow up question while we are in this topic...

Why are msg/ortho/hospital podiatrists significantly higher compensated than a podiatrist who is not in one of these setups? Assuming location is the same and we are not talking about a PP owner with a well-oiled practice seeing 100+ patients that took 10+ years to build. Is it because the msg/ortho/hospital is able to negotiate higher percentages of reimbursements? Hence the podiatrist can take advantage of these contracts and get reimbursed at higher percentages for everything they do from clinic to the operating room? If this is the case are the reimbursement percentages the same an ortho F&A would get paid if they were doing the same clinic procedures and surgical cases in one of these setups or is it still an inferior reimbursement percentage than an ortho F&A would get however still superior to podiatrists who are not in these setups?

-Or-

Is it the fact that msg/ortho/hospital are more selective with which insurers they take? Which intuitively does not make sense to me as you'd think hospitals will take most if not all insurances and I don't know personally but I'm guessing msg/ortho groups that take the lower-end insurances are still making far and beyond what your typically quoted here on SDN average podiatrist makes, 120-150k.

I'd really appreciate some feedback. Thank you.

One of the docs I trained with in residency was in PP, but had formerly been employed by the biggest hospital system in town. He claimed the referrals department screened patients by insurance and directed patients with better-paying plans to hospital employed docs and sent the lower-paying plans to community docs. While I can't prove his story, it would be pretty easy to set up referrals in EPIC to "nudge" referring providers in a certain direction.

 

[air bud]

Has been talked about ad nauseam. You are paid more as an employed doc because of other money you generate for the hospital. Also RVUS vs fee for service. Spend some time reading other threads related to MSG/hospital gigs.

edit - although its not like these threads stay on topic...

 

[NobodyDPM]

Thanks everyone, once again I appreciate the feedback. I think I get the picture.

As follow up question while we are in this topic...

Why are msg/ortho/hospital podiatrists significantly higher compensated than a podiatrist who is not in one of these setups? Assuming location is the same and we are not talking about a PP owner with a well-oiled practice seeing 100+ patients that took 10+ years to build. Is it because the msg/ortho/hospital is able to negotiate higher percentages of reimbursements? Hence the podiatrist can take advantage of these contracts and get reimbursed at higher percentages for everything they do from clinic to the operating room? If this is the case are the reimbursement percentages the same an ortho F&A would get paid if they were doing the same clinic procedures and surgical cases in one of these setups or is it still an inferior reimbursement percentage than an ortho F&A would get however still superior to podiatrists who are not in these setups?

-Or-

Is it the fact that msg/ortho/hospital are more selective with which insurers they take? Which intuitively does not make sense to me as you'd think hospitals will take most if not all insurances and I don't know personally but I'm guessing msg/ortho groups that take the lower-end insurances are still making far and beyond what your typically quoted here on SDN average podiatrist makes, 120-150k.

I'd really appreciate some feedback. Thank you.

Bolded mine. Yes, that's one of the big reasons.

I mentioned this in another thread that large groups (like ones owned by hospitals, or the hospitals themselves) have real negotiating power. Especially if they are the only game in town. They can virtually dictate their non Medicare/Medicaid fee schedules. And if it's done as a group, it's not illegal.

The other thing, too, is that some big hospital systems own their own insurance companies. Sentara in the Mid East owns Optima insurance. There is a system like that in Louisiana as well. I think it's called Omni? Kaiser Permanente in California is another example. Way back when, Cigna had a foot hold in Texas through the back door. So, if you work for them, they will "negotiate" a higher fee schedule. It's really quite a scam.

And as someone else mentioned, you sending your patients for CTs, MRIs, PT and doing surgery within the system you work for also makes them money.

I'm not exactly sure how these big corporations are skirting the anti-trust laws. Probably because they own the politicians as well.

 

[NobodyDPM]

One of the docs I trained with in residency was in PP, but had formerly been employed by the biggest hospital system in town. He claimed the referrals department screened patients by insurance and directed patients with better-paying plans to hospital employed docs and sent the lower-paying plans to community docs. While I can't prove his story, it would be pretty easy to set up referrals in EPIC to "nudge" referring providers in a certain direction.

I can confirm this happens. Also, a lone podiatrist who takes the insurance is reimbursed less for the same procedure than a podiatrist who works for the hospital system. And no it's not illegal. And remember, the podiatrist who works for the system doesn't actually "see" that extra reimbursement. The hospital system does. What's terrible is that if the hospital system also owns the insurance company, they negotiate with themselves for higher reimbursement. Kinda crazy. Explained above.