Working in Boondocks for High Salary

[fj25]

Is it true that you can sign a contract for a coulpe of years and work in the middle of nowhere for a couple of years, make some money and get the hell out of there?

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[Winged Scapula]

Is it true that you can sign a contract for a coulpe of years and work in the middle of nowhere for a couple of years, make some money and get the hell out of there?

It is not unheard of to earn more than the average when working in a geograhically undesirable area. The contract details are up to you and the hiring practice/institution. Be prepared to work for that money - often times you may be the only specialist in the area, so you take more call, work longer hours, etc.

I get frequent ads for general surgery positions paying 400K+ in less then desirable areas - however, they often require 1 in 2 call, which IMHO isn't worth the extra $$.

 

[Shodddy18]

It is not unheard of to earn more than the average when working in a geograhically undesirable area. The contract details are up to you and the hiring practice/institution. Be prepared to work for that money - often times you may be the only specialist in the area, so you take more call, work longer hours, etc.

I get frequent ads for general surgery positions paying 400K+ in less then desirable areas - however, they often require 1 in 2 call, which IMHO isn't worth the extra $$.

Any examples of some of these locations?

 

[Solideliquid]

It is not unheard of to earn more than the average when working in a geograhically undesirable area. The contract details are up to you and the hiring practice/institution. Be prepared to work for that money - often times you may be the only specialist in the area, so you take more call, work longer hours, etc.

I get frequent ads for general surgery positions paying 400K+ in less then desirable areas - however, they often require 1 in 2 call, which IMHO isn't worth the extra $$.

Sorry if this seems like a stupid question, but can you please explain what 1 in 2 call means? I've never heard it stated like that, and I guess I should know as a new intern.

Thanks!

 

[gutonc]

Sorry if this seems like a stupid question, but can you please explain what 1 in 2 call means? I've never heard it stated like that, and I guess I should know as a new intern.

Thanks!

Same as Q2. I think that's prohibited w/ the 80 hour work week schedule but I don't know for sure. In any event, once you're out of a residency/fellowship program, the 80 work week doesn't apply so it doesn't much matter.

BE (now PE)

 

[MossPoh]

Well the "less than desireable" thing is really really subjective. People tend to think of 500 person towns and stuff but even a 50 to 100 k town can be considered less than desireable if it is in the midwest and has other stuff going on. The town I am currently in is having a pain trying to find pretty much all physicians but since Cox mentioned it with the 1 in 2 stuff..I'll go with surgery. Currently we have 2 general surgeons in this town...they are doing up to 7 or 8 surgeries a day including up to 3 or 4 gallbladders in one day....There were 4 but one retired, and another opened a breast clinic. They are getting to the point where they are desperate and about to offer large amounts of money simply to relieve the stress of doing such large amounts of procedures and working 80 or more hours in a week.

 

[Winged Scapula]

Sorry if this seems like a stupid question, but can you please explain what 1 in 2 call means? I've never heard it stated like that, and I guess I should know as a new intern.

Thanks!

Yes, 1 in 2 call = q2. Most ads for jobs don't use the residency terminology if "qx".

As noted, above, they (your potential employer) can ask you to do whatever call they like since there are no work hour restrictions.

 

[Winged Scapula]

Same as Q2. I think that's prohibited w/ the 80 hour work week schedule but I don't know for sure. In any event, once you're out of a residency/fellowship program, the 80 work week doesn't apply so it doesn't much matter.

BE (now PE)

its prohibited in residency, but since the OP and I were talking about jobs after residency, the work hour rules don't apply.

 

[Winged Scapula]

Well the "less than desireable" thing is really really subjective. People tend to think of 500 person towns and stuff but even a 50 to 100 k town can be considered less than desireable if it is in the midwest and has other stuff going on. The town I am currently in is having a pain trying to find pretty much all physicians but since Cox mentioned it with the 1 in 2 stuff..I'll go with surgery. Currently we have 2 general surgeons in this town...they are doing up to 7 or 8 surgeries a day including up to 3 or 4 gallbladders in one day....There were 4 but one retired, and another opened a breast clinic. They are getting to the point where they are desperate and about to offer large amounts of money simply to relieve the stress of doing such large amounts of procedures and working 80 or more hours in a week.

This is exactl the typical situation - its not always some Podunk town in the middle of nnowhere, but can be a relatively larger town but in a place that gets lots of snow, or has few outlets for single people, or is mostly lower income, etc. "Undesirable" is really up to you - right now, the east coast is undesirable to me, mostly for family reasons (and the bad drivers here in Jersey), but plenty of others would love to be here, I'm sure.

Many places have had physicians leave and they are stuck with little manpower and find themselves working like dogs (as in the example above), and willl pay nearly anything to get someone into the practice.

 

[flighterdoc]

What size town can support something called a hospital (defined as being able to treat and keep people o'nite, and not a con home)?

I'd imagine that the very small towns (<2,000 or so) certainly can't, and I typically see hospitals and clinics with over 5K or so.... but, I haven't really looked hard at it.

At some point the demographics of the town and catchment area just can't support the hospital.

 

[sophiejane]

Is it true that you can sign a contract for a coulpe of years and work in the middle of nowhere for a couple of years, make some money and get the hell out of there?

What would stop anyone from doing that? You never have to renew a contract if you don't want to. And what you get paid is what the going rate is. Sometimes it's higher in underserved areas, sometimes it's lower.

There are loan repayment programs that effectively increase your pay by $30-40K a year because they pay you a competitive salary and on top of that, knock off sizeable chunks of your debt in return for your service to the underserved.

 

[huskymed06]

What size town can support something called a hospital (defined as being able to treat and keep people o'nite, and not a con home)?

I'd imagine that the very small towns (<2,000 or so) certainly can't, and I typically see hospitals and clinics with over 5K or so.... but, I haven't really looked hard at it.

At some point the demographics of the town and catchment area just can't support the hospital.

Consider Sharon, CT population 2968 with Sharon Hospital the state's only for profit hospital.

http://www.sharonhospital.com/
http://en.wikipedia.org/wiki/Sharon,_Connecticut

 

[ckyuen]

400k for general surgery, they must work you like a dog or it will be a guarantee for only a year or so then you will be expected to earn your keep. There are no free lunches remember no matter what a recruiter tells you. I remember these adds and they will always say ideal location near mountains, beaches, universities, great school districts, paying two or three times the normal starting salary, they all don't pan out. A lot of them are hospitals subsidizing the physician and after a year there is not enough business to allow you to earn that income. Or like someone pointed out earlier you work so hard it's not sustainable.
By the way I thought medicare only paid g surgeons like 150.00 or 200.0 for an appendectomy, what do they pay for a lap chole, I imagine it's much more. but if insurances only pay like 130% of medicare which is generous, that's not a lot for an appy. I guess you guys must do a lot of them.
Also, speaking to my anesthesiologist he gets like 100.00 for a cataract, that's not a lot. luckily he has very low overhead, just one scheduler. medicaid pays him more than medicare, and private insurance pays 2.5 x as much. I can see making money on the private cases, but boy the other cases barely pay the bills.
My point of view is very skewed by our incredibly high overhead in ophtho. Our practice overhead can run into 7 figures for the two of us. So in ophtho you have to see a lot of people and do a lot of surgery to survive.

 

[Winged Scapula]

400k for general surgery, they must work you like a dog or it will be a guarantee for only a year or so then you will be expected to earn your keep. There are no free lunches remember no matter what a recruiter tells you. I remember these adds and they will always say ideal location near mountains, beaches, universities, great school districts, paying two or three times the normal starting salary, they all don't pan out. A lot of them are hospitals subsidizing the physician and after a year there is not enough business to allow you to earn that income. Or like someone pointed out earlier you work so hard it's not sustainable.
By the way I thought medicare only paid g surgeons like 150.00 or 200.0 for an appendectomy, what do they pay for a lap chole, I imagine it's much more. but if insurances only pay like 130% of medicare which is generous, that's not a lot for an appy. I guess you guys must do a lot of them.
Also, speaking to my anesthesiologist he gets like 100.00 for a cataract, that's not a lot. luckily he has very low overhead, just one scheduler. medicaid pays him more than medicare, and private insurance pays 2.5 x as much. I can see making money on the private cases, but boy the other cases barely pay the bills.
My point of view is very skewed by our incredibly high overhead in ophtho. Our practice overhead can run into 7 figures for the two of us. So in ophtho you have to see a lot of people and do a lot of surgery to survive.

That's the point we were making - yes, its possible to make good money doing general surgery (or something else) in the boonies, but there's usually a catch. The call is horrendous, the patient population is largely uninsured, the pay is only for a year, etc.

Lap choles are NOT paid much more than appys...the reimbursement for many general surgical procedures is poor, given the training time and expertise involved. Its one reason why private practice is very hard to sustain these days - unless you work a lot, or concentrate on more billable procedures, you can't cover the overhead or malpractice without established partners willing to help you along in the beginning or to work for a hospital or other established institution.

 

[Winged Scapula]

Here's an example of the kind of money you can make, being the "only show in town"...

Opportunity: J-GS-NV-949
Specialty: GENERAL SURGERY
Location: Nevada
Region: West
Description:
Bread and butter, General Surgery. Diverse community. No other surgeon in town, so will be busy from day 1. No state tax, 7% Medicaid, 40% Medicare, 10% PP, 30% HMO/PPO. Salary $600k a year or $43,00 a month for first 2 years. One of the fastest growing cities in NV. A little over 1 hour to Las Vegas. For details, please call our recruiters at 602-266-4777 or 800-899-2200.

 

[ckyuen]

I'd believe that salary only after looking at the contract. There is no way they could pay you 600k without losing about 300k on you. they must be really desperate for a surgeon, or risk losing some other major source of revenue. Maybe they are funding the salary with a major portion of the or fees. I know for a cataract the hospital gets twice what I receive for the procedure. The other thing to watch out for with a salary like this is that it is most likely in the form of a loan. A couple of scenerios it could be forgiven if you stay for 5 or 7 years, and after first two years with that payor mix you maybe go to making 200k for the next five years. Or the salary may have collections requirements attached to it. Being the only show in town by the way sucks because you are one call 365 days a year. The ER will know where to find you believe me. I'm not even on call for one of the hospitals in town and they call me every weekend. And there are 5 other ophthalmologist on staff.

 

[Winged Scapula]

I'd believe that salary only after looking at the contract. There is no way they could pay you 600k without losing about 300k on you. they must be really desperate for a surgeon, or risk losing some other major source of revenue. Maybe they are funding the salary with a major portion of the or fees. I know for a cataract the hospital gets twice what I receive for the procedure. The other thing to watch out for with a salary like this is that it is most likely in the form of a loan. A couple of scenerios it could be forgiven if you stay for 5 or 7 years, and after first two years with that payor mix you maybe go to making 200k for the next five years. Or the salary may have collections requirements attached to it. Being the only show in town by the way sucks because you are one call 365 days a year. The ER will know where to find you believe me. I'm not even on call for one of the hospitals in town and they call me every weekend. And there are 5 other ophthalmologist on staff.

My point was that exactly - there are usually "catches" to these kind of offers, but it does satisfy the OP's question about whether it was possible to work in the Boonies for big bucks. Now whether or not you can leave after a couple of years, remains to be seen when the contract is on the table. I think the rest of the answer as to why the salary is so high lies in the description of the position...

NO OTHER SURGEON IN TOWN (ie, you are on call EVERY night. This would get pretty darn tiring, not to mention no time for your family or social life.)

YOU WILL BE BUSY FROM DAY 1 (Really? I can't imagine that being the only surgeon in town. Interesting how most other fields highlight how "un-busy" you will be for such great pay when surgical fields talk about how busy you'll be.)

$600,000 K or $43,000/ month for the FIRST TWO YEARS (ie, after that you are on performance based pay, probably at a lower reimbursement)

These kind of salaries ARE possible, but you work like a dog and in many cases, the high salaries are only guaranteed for the first year or two. After that, you'd better continue to work like a dog, bringing in the billables, so you can sustain that salary, or at least the lifestyle you've by then become accustomed to.

 

[ckyuen]

If appys and lap choles are you bread and butter you will be working more than residency to collect 43000 a month. Is there a global on lap choles and appys? if there isn't then I can see how you could collect much more but if you have the 90 day global like all major optho surgeries there is no way you can collect 43000 after overhead. if you assume a 35-40% overhead which is pretty low, that means you need to collect like 70k a month. if an appy pays 200.00 then that's a crapload of appys, now if there is no global, depending on how frequently you need to follow these patient collectables can increase b/c you'll get about 50.00 for each f/u and about 140.00 for intitial consult with decision for major surgery. For ophtho 70k a month is not a lot to collect, but overhead is more like 60-70 % if not higher, so you have to collect a lot more. We have a ton of machines you need to buy and we have to see a lot of patients which means a lot of ancillary staff. But if you believe that you can collect the amount possible to keep 43000 a month more power to you, you must be an incredibly hard worker who believes sleep is not a necessity. at about 400.00 a patient including preop consult, and the surgery that's about 160 procedures a month. if they take a half hour each, with or turnover travel time etc, that's a bunch of time. you would have to work at least 120 hours a week. That's why I say they may be telling you 43k salary, but look at the fine print they may only be offering 43k guaranteed collections, they you pay overhead. Most important thing in looking for a job, there is no free lunch, people will take advantage of you if you let them. Don't look for some ridiculous job that most likely doesn't exist, instead pick the area you want to be in, network with the docs there and a lot will come of it. I got a lot of offers in a very desireable area of the country with a salary higher than national average.

 

[flighterdoc]

Consider Sharon, CT population 2968 with Sharon Hospital the state's only for profit hospital.

http://www.sharonhospital.com/
http://en.wikipedia.org/wiki/Sharon,_Connecticut

Yeah, but Ct is so small their catchement area is the entire state and surrounding areas.

 

[MacGyver]

Here's an example of the kind of money you can make, being the "only show in town"...

Opportunity: J-GS-NV-949
Specialty: GENERAL SURGERY
Location: Nevada
Region: West
Description:
Bread and butter, General Surgery. Diverse community. No other surgeon in town, so will be busy from day 1. No state tax, 7% Medicaid, 40% Medicare, 10% PP, 30% HMO/PPO. Salary $600k a year or $43,00 a month for first 2 years. One of the fastest growing cities in NV. A little over 1 hour to Las Vegas. For details, please call our recruiters at 602-266-4777 or 800-899-2200.

My bet is thats a phantom offer.

Job recruiters are scumbags. They make up BS lies and put them in the newspaper or other job search marketing tool. Then when you call them or actually get a real contract to look at, they pull a "bait and switch" on you, either claiming that job is now gone and trying to hook you on a MUCH less lucrative job, or by using fancy lawyer trickery in contract form to make sure you never collect that amount.

Bear in mind that these say job recruiter scumbags have their mouthpieces connected to major media outlets, claiming theres a huge doctor shortage according to their recruiting efforts. Lies I tell you, all lies. They are motivated by increased retainer fees to scream to everyone that theres a doctor shortage when in reality none exists.

Job recruiters are on the same moral equivalency level as lawyers. You cant trust a damn thing they tell you.

 

[Winged Scapula]

If appys and lap choles are you bread and butter you will be working more than residency to collect 43000 a month. Is there a global on lap choles and appys? if there isn't then I can see how you could collect much more but if you have the 90 day global like all major optho surgeries there is no way you can collect 43000 after overhead. if you assume a 35-40% overhead which is pretty low, that means you need to collect like 70k a month. if an appy pays 200.00 then that's a crapload of appys, now if there is no global, depending on how frequently you need to follow these patient collectables can increase b/c you'll get about 50.00 for each f/u and about 140.00 for intitial consult with decision for major surgery. For ophtho 70k a month is not a lot to collect, but overhead is more like 60-70 % if not higher, so you have to collect a lot more. We have a ton of machines you need to buy and we have to see a lot of patients which means a lot of ancillary staff. But if you believe that you can collect the amount possible to keep 43000 a month more power to you, you must be an incredibly hard worker who believes sleep is not a necessity. at about 400.00 a patient including preop consult, and the surgery that's about 160 procedures a month. if they take a half hour each, with or turnover travel time etc, that's a bunch of time. you would have to work at least 120 hours a week. That's why I say they may be telling you 43k salary, but look at the fine print they may only be offering 43k guaranteed collections, they you pay overhead. Most important thing in looking for a job, there is no free lunch, people will take advantage of you if you let them. Don't look for some ridiculous job that most likely doesn't exist, instead pick the area you want to be in, network with the docs there and a lot will come of it. I got a lot of offers in a very desireable area of the country with a salary higher than national average.

Uhmmm....yeah. I think we are ALL in agreement that there is no free lunch, that offers like that above are fraught with loopholes (I'm sure the $43,000 per month is gross and does not include office fees, malpractice, etc.). I'm not sure the point you and MacGyver are making, unless it is to warn the OP about such offers.

 

[Louisville04]

if an appy pays 200.00 then that's a crapload of appys, now if there is no global, depending on how frequently you need to follow these patient collectables can increase b/c you'll get about 50.00 for each f/u and about 140.00 for intitial consult with decision for major surgery.

Wow that is surprisingly low. I would assume a procedure would reimburse significantly more than a non surgical treatment. I assumed surgeons generally made more than internists..however with those reimbursement figures I would say they are about equal.

 

[Winged Scapula]

Wow that is surprisingly low. I would assume a procedure would reimburse significantly more than a non surgical treatment. I assumed surgeons generally made more than internists..however with those reimbursement figures I would say they are about equal.

The numbers vary whether its private insurance or MediCare reimbursing you but the pay for surgical procedures and consults has DECREASED over the last several years and is not in, general, very impressive.

However, it is true that most procedure based specialties still make more than a non-procedural based one (like IM, although some IM fellowships can train you in procedures which are billable), its just that the scale has not increased with inflation/cost of living and has in fact, decreased to a level where some feel its not profitable for all the work and training involved.

 

[mackie]

No other surgeon in town, so will be busy from day 1.

That line alone should make potential jobseekers RUN for the hills!

I receive offers in the mail all the time for Int medicine positions, some paying over $200K. I never really considered there being big catches. Thanks for starting this thread. Point taken . . . read every single line of the job contract before signing.

 

[dawg44]

These deals are out there and its all a bait and switch. It may look like they are losing money on you, but they HAVE to have you. You make the place run and they make it back in facility fees for surgery, admissions, Labs, Radiology. These stats are available and I have talked to CEOs about this. A hospital generates 1.5 million in charges for a orthopedic surgeon doing typical volume so after they pay there expenses it is about 700,000 in revenue. That has nothing to do with what you make. Thats what the hospital makes by having you work in their system and that is for a guy that just does avg. volume. Hospitals are going to make money don't worry about that and they are offering big bucks for a reason. They have to keep the machine running and their is a big shortage right now.
I think there are few things to do for this to work or at least protect yourself.
1) It has to be an employed position. If it is a smaller town in the middle of nowhere you don't want to be buying assets or owning real estate if you decide to leave. A lot of hospitals once the guarantee is over your income drops dramatically and they have you stuck in a town because you are now a owner in your practice. Eliminate that by being employed with a very high salary with a production model.
2) Don't overspend on your house. It could be very hard to unload a 400,000 dollar house in a town of 10,000 than it would in a town of 100,000. Just not near as many people can afford it. It is tempting to buy a huge house with your buying power in a small town in the middle of nowhere, but don't do it. Buy a nice house and a cabin or lake house somewhere else.
3) Paid tail coverage Most employed positions will do this because if you don't pay your tail you open up the hospital for liabillity. They usually go ahead a cover this.
4) Spell out the ER call you will take in your contract. Tell them you might take more but that is negotiable in amount and compensation at your discretion. Alot of times they will hire a PA to help with this as well.
5) Know the ins and outs of the contract and be ready to move or threaten to move. You are a commodity and if they know you can leave very easily, what you say goes and they have every incentive to keep you happy. If you are tied into a big signing bonus or anything else there is less motivation on their part.
6) Don't have them pay your loans off in one lump sum. If you leave and haven't finished your contract you could owe them alot of money plus interest and you have already paid taxes on that. Have them send a check after every year you finish there.