Yet Another "First Job After Fellowship Advice" Post

[QuarterNote]

Hi All,

First and foremost, this forum has been an amazing resource for my own journey, so thanks in advance for any and all help.

I find myself in a situation I can't seem to get answers to elsewhere on these threads. Briefly, I'm looking into jobs for my first year out of fellowship. I am EM trained, and currently plan to a hybrid of locums/per diem ED shifts while supplementing part time pain 2-3d/week. That could easily change in the future, but for now it's what I'm after.

I've been speaking with a pain practice on the east coast. Will spare all the details, but it's private, single owner with 2 NP's, owns own ASC, established for 15 years. He is interested in bringing on a new part-time doc for 2-3 days per week to help take some of the load off as he hopes to retire in the next 10 years or so. His ultimate goal is to bring on an eventual partner. We've met in person and vibe well.

So my question: What would the most ideal contract/payment structure look like for 2-3 days per week of pain? This would primarily be injections, 15-20/d as far as I can tell. I was initially thinking a base salary around $150-200k and I'd supplement with ED shifts around the edges, but upon speaking with other mentors, a fee-for-service model might make the most sense. This would somehow need to be tied into benefits, malpractice, etc...

I know this is very limited information and there are countless factors at play, but ultimately has anyone explored or experienced this type of situation? Pearls and pitfalls to avoid? They are open to pretty much anything because they also haven't hired part time employees before. As stated, the ultimate goal would be eventual partnership talks, but I'm wondering how to negotiate the initial 2-3 day per week model in terms of contract discussions, particularly as a new and admittedly impressionable grad...

Thanks in advance!

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[SgtThunderfistMD]

FYI I think the elder-statesmen here often warn about being some old doc's needle jockey, doing injections on people you never evaluated in clinic.

 

[Ronin1]

FYI I think the elder-statesmen here often warn about being some old doc's needle jockey, doing injections on people you never evaluated in clinic.

I resent the word elder lol but essentially that’s correct .

I think the odds of a fair partnership possibility are zero in the case presented. Might as well open your own shop with this scenario

 

[Agast]

OP are you intentionally trying to do a few days of EM a week, or is that what you would need to do in order to make this job offer work?

It’s very hard to grow a pain practice if you’re mainly doing procedures. The patients will have little to no relationship with you and therefore no reason to stay with you after the primary doctor or NPs they see in clinic leave.

 

[QuarterNote]

Haha let it be known I was not the one who brought the word "elder" to this conversation...

Thanks for the replies, and yes I can definitely see the risk/complication of just showing up for procedures with patients I haven't evaluated. I think they've been running off this model for multiple years.

@Agast initially it's my choice to do some EM on the side, but I hear your point that it's very hard to grow a pain practice under this scenario. Being realistic with myself, I will likely not do EM in a few years but I want to do a hybrid in the beginning of my career. Part of it is to explore every different option available to me while I am young, flexible, without kids, etc.

I have a colleague who is currently doing procedures for a radiologist group 2d/week and per diem EM shifts the rest of the time with decent success, so I know it's at least possible.

If I were to move forward, do you all think a fee for service structure would make the most sense?

Thanks again!

 

[deleted875186]

I have no idea how the compensation structure would work for this, but why not simply suggest a dollar amount per RVU for your compensation.

Also, unless you’re really attached to this area or think the practice has great long term potential, to me it seems to be a waste of time to enter into this 2-3 days per week practice. Probably you want to see all your own patients starting out, especially if your unsure what you want your job to be a few years from now. Why continue ED? You already know what it entails. It seems you’re unsure if you want to practice pain full time and so want to keep up your ED skills, which is fine, but if this is the case I would suggest just go full time pain and switch back in a year if your unhappy.

 

[deleted131481]

Sounds like fee for service at ASC is a not a good deal for you.

 

[Baron Samedi]

Seeing clinic makes you a better doctor. Doing solely procedures makes you a technician. Would not recommend for your first job out of fellowship.

 

[DrMDAware]

If you’re doing 2-3 days of 20-30 cases per day you’re likely generating a very healthy amount of facility fees.

Depending on patient mix, cases, location I’m guessing welllll over 1-2 MM

 

[Hoya11]

Hi All,

First and foremost, this forum has been an amazing resource for my own journey, so thanks in advance for any and all help.

I find myself in a situation I can't seem to get answers to elsewhere on these threads. Briefly, I'm looking into jobs for my first year out of fellowship. I am EM trained, and currently plan to a hybrid of locums/per diem ED shifts while supplementing part time pain 2-3d/week. That could easily change in the future, but for now it's what I'm after.

I've been speaking with a pain practice on the east coast. Will spare all the details, but it's private, single owner with 2 NP's, owns own ASC, established for 15 years. He is interested in bringing on a new part-time doc for 2-3 days per week to help take some of the load off as he hopes to retire in the next 10 years or so. His ultimate goal is to bring on an eventual partner. We've met in person and vibe well.

So my question: What would the most ideal contract/payment structure look like for 2-3 days per week of pain? This would primarily be injections, 15-20/d as far as I can tell. I was initially thinking a base salary around $150-200k and I'd supplement with ED shifts around the edges, but upon speaking with other mentors, a fee-for-service model might make the most sense. This would somehow need to be tied into benefits, malpractice, etc...

I know this is very limited information and there are countless factors at play, but ultimately has anyone explored or experienced this type of situation? Pearls and pitfalls to avoid? They are open to pretty much anything because they also haven't hired part time employees before. As stated, the ultimate goal would be eventual partnership talks, but I'm wondering how to negotiate the initial 2-3 day per week model in terms of contract discussions, particularly as a new and admittedly impressionable grad...

Thanks in advance!

With all due respect , your premise of doing EM and Pain mix is going to cost you success and money in both careers… pick one and dedicate yourself to that.

FWIW I think a fair value is 100k per day per week in Pain. Meaning that if you do 3D per week for the full year then you ask for a 300k salary plus benefits.

I think you will struggle with this arrangement until you decide on a path that makes more sense. Mix of anesthesia and pain or pmr and pain is more doable as it’s the same department.. EM and pain is going to hurt you

 

[Ducttape]

as a former ER doc, i would not recommend.

first, you should be all in on being this guys partner so you can eventually take over his practice.

it seems that he could work with you a bit, then decide to sell the practice to someone else, and you would be "left at the altar".

i would suggest you work full time with the goals of being a partner, with the expectation that you will do some per diem shifts to generate extra income while building up your practice.


otoh, it sounds like he wants to vet you to see if you would be a good fit and is not willing to make a commitment to you. sounds like he wants the option to jettison you as soon as the right partner candidate comes along...

 

[Agast]

Someone near the end of their career is looking for someone to buy their practice, not buy into it. He can charge you twice as much to purchase the practice than to sell partnership shares.

 

[deleted875186]

With all due respect , your premise of doing EM and Pain mix is going to cost you success and money in both careers… pick one and dedicate yourself to that.

FWIW I think a fair value is 100k per day per week in Pain. Meaning that if you do 3D per week for the full year then you ask for a 300k salary plus benefits.

I think you will struggle with this arrangement until you decide on a path that makes more sense. Mix of anesthesia and pain or pmr and pain is more doable as it’s the same department.. EM and pain is going to hurt you

No way somebody is going to pay 300k plus benefits for 3 days for someone straight out of training. Some parts of the country will offer new grads 300k plus benefits for a full time job.

 

[agolden1]

as a former ER doc, i would not recommend.

first, you should be all in on being this guys partner so you can eventually take over his practice.

it seems that he could work with you a bit, then decide to sell the practice to someone else, and you would be "left at the altar".

i would suggest you work full time with the goals of being a partner, with the expectation that you will do some per diem shifts to generate extra income while building up your practice.


otoh, it sounds like he wants to vet you to see if you would be a good fit and is not willing to make a commitment to you. sounds like he wants the option to jettison you as soon as the right partner candidate comes along...

Was thinking this. Glad someone beat me to it.

 

[Hoya11]

No way somebody is going to pay 300k plus benefits for 3 days for someone straight out of training. Some parts of the country will offer new grads 300k plus benefits for a full time job.

I dont know, I get offers in my email for ">500k+ no weekends no call"

 

[QuarterNote]

Hi all,

Thank you so much for taking the time to honestly share your thoughts and feelings regarding my situation. It definitely helps wrap my mind around the pros and cons. I obviously don't want to write a novel here so I'll try to bullet point in no particular order:

1. I certainly hear the risks about being a "needle junkie" and proceduralist vs actual physician. I believe the model he's after includes clinic time as well, even if it's one day clinic and one day procedures, so I'll continue getting that experience (albeit limited). I also think he's hoping to increase the number of days once things get settled, with 3-4 being the endgame. I understand it would be ideal to have this clearly laid out in writing, along with specifics regarding partnership track.
2. If I were to move forward, it looks like the $$/RVU model would make the most sense and offer the most flexibility.
3. I don't totally see the difference between an individual doing something like anesthesia call once/week alongside pain and my doing an EM shift. Sure the medicine is different, anesthesia can utilize pain with in-patient pumps, blocks, etc, but ultimately aren't they both mixing two skillsets to shake the week up a little? Being under the same department is helpful, but there are plenty of hybrid careers out there in medicine far as I can tell.
4. I also recognize the risk of being left behind in case the partnership track doesn't work, but I view this as a mutual experiment between him and I. With nearly 50%+ docs leaving their first job within 5-years these days, I don't feel like this scenario is too uncommon? If it works out great between us that would be ideal, but finding a perfect first job feels like finding a soul-mate off a first date, and I haven't had much luck in the latter
5. I will fully acknowledge this is a track that I am unfamiliar with, and that it comes with inherent risks, but if a career that includes 2-3d/pain plus some ED shifts as needed is possible, I'd want to figure that out sooner rather than later. I also think I'll have a much better idea of what's possible and expected once our formal contract discussions start. I'm hoping that'll be in the next 2-3 weeks and I will definitely be looking to chime in on this page.

Thank you again for taking the time to offer your advice, and please continue to do so. I'll remain all-ears and open to any thoughts, and will be sure to check in as things unfold!

 

[Bostonspine]

I dont know, I get offers in my email for ">500k+ no weekends no call"

You should ask them what happened to the last guy…😂 laughs in Boston. Even if he’s coming and just doing procedures the are probably gonna factor the mid levels evaluating the patients and who ever is taking call for all the problems that support you IR lifestyle…

 

[Ducttape]

crazy evening and night shifts in the ER take a toll off of you that you probably would not see as much in anesthesia gigs.

the key is to see if you could set up the ER shifts so they give you plenty of time to rest before going to pain. im sure there are a lot of ERs that would be happy for you to be their Friday night and Saturday night guy.

you definitely can do both at the same time. i would suggest you be a little wary of the potential for burn out.

 

[Agast]

You can refer all your drug-seeking ER patients to yourself

 

[GatorCHOMPions]

@QuarterNote I do full time pain and per diem EM, usually 2-3 weekend day shifts per month. It’s possible but certainly tough. You’ll gain appreciation for how easier the money comes with Pain, once you get established, on top of less stress. Sometimes I feel like a lot of the whining posts on here don’t get that aspect. Pain is pretty nice relatively speaking. I can’t see myself continuing EM for more than a few years, if that.

 

[deleted875186]

@QuarterNote I do full time pain and per diem EM, usually 2-3 weekend day shifts per month. It’s possible but certainly tough. You’ll gain appreciation for how easier the money comes with Pain, once you get established, on top of less stress. Sometimes I feel like a lot of the whining posts on here don’t get that aspect. Pain is pretty nice relatively speaking. I can’t see myself continuing EM for more than a few years, if that.

Interesting perspective, because I feel as though anesthesia is much less stressful than pain, just have to do some call shifts.

The nighttime busy ED shifts do seem like they can take a toll over time.

 

[Gauss]

@QuarterNote I do full time pain and per diem EM, usually 2-3 weekend day shifts per month. It’s possible but certainly tough. You’ll gain appreciation for how easier the money comes with Pain, once you get established, on top of less stress. Sometimes I feel like a lot of the whining posts on here don’t get that aspect. Pain is pretty nice relatively speaking. I can’t see myself continuing EM for more than a few years, if that.

this is the consensus from all my EM colleagues. Don't think any of them pick up shifts anymore, 100% outpatient clinic.

 

[Ferrismonk]

Interesting perspective, because I feel as though anesthesia is much less stressful than pain, just have to do some call shifts.

The nighttime busy ED shifts do seem like they can take a toll over time.

Until you're dealing with a uterine rupture or doing a big case on someone who has both terrible CHF and ESRD.

 

[mdo1738]

Interesting perspective, because I feel as though anesthesia is much less stressful than pain, just have to do some call shifts.

The nighttime busy ED shifts do seem like they can take a toll over time.

interesting perspective, i find anesthesia to be a million times more stressful than pain

 

[drrosenrosen]

They're both stressful, in different ways.

 

[specepic]

I can understand the comments about doing ALL pain or ALL ER; that being said I can say at my hospital there would be a place for this arrangement (some ER, some Pain), and I suspect at other hospital employed set ups. probably tougher re: private practice where you probably have to be all in

 

[manowar rules]

interesting perspective, i find anesthesia to be a million times more stressful than pain

I still get palpitations when I hear a pager go off. And waking you up from your sleep! That should be a human rights violation

 

[Agast]

I still get palpitations when I hear a pager go off. And waking you up from your sleep! That should be a human rights violation

Or worse yet, when you wake up to the beeping and you realize there are 4 other pages you slept through

 

[drrosenrosen]

Or worse yet, when you wake up to the beeping and you realize there are 4 other pages you slept through

Last time I took call was doing some locums anesthesia at my old hospital before I started my current job. I was on for weekend nights. No pagers - the house sup calls your cell phone says "we've got a case, come in". It's a pretty quiet place usually, so I didn't really panic when I woke up in the morning not having been called. Until later that day when I apparently left the cell coverage hole I didn't realize I had been in, and got 4 voice messages all at once, first from the operator, then from the cardiac call guy who'd been called in because they couldn't reach me.

It was the ultimate "oh no I didn't study for this test" nightmare, come to life. I gave the guy my call pay for that night. Fortunately we're friends and he's a really lovely guy so he didn't take it too hard.

 

[oreosandsake]

Have you considered this kind of offering

 

[nvrsumr]

🤮

 

[lobelsteve]

Have you considered this kind of offering

1.53 rvu x 50/d x 225 days per year.
17212 per year.
$13.94 per rvu.

 

[oreosandsake]

1.53 rvu x 50/d x 225 days per year.
17212 per year.
$13.94 per rvu.

But the clinician can train the provider! 😂