Help me evaluate Job offer (Physician)

[darkhorse]

Hello fellow bogleheads,

I have been facing intense dilemma over my job situation. Part of me wants to just stick with my current job. Unclear if it is due to loss aversion or easier schedule on day to day basis. However, there are distinct advantages (and disadvantages) with new offer and will appreciate any advice or fresh insight.

I am including pertaining information below but will be happy to provide anything additional that's needed.


Background:

I took a job after fellowship three years ago. I am happy with area I live in and so would like to remain in the same area. While I am generally happy with my current job, main challenge has been coverage for vacation/weekend. My practice is inpatient/outpatient 70/30. Over last nine months, I have engaged to i) ensure coverage for vacation/weekend ii) negotiate for revised contract

They agreed to increase salary and in principle agree to obtain coverage but no commitment on timeline. I have some coverage arrangement in place that allows me to have two weekends off a month and over last six months was able to also take some vacation but it is not reliable and not on my own terms.

Scenario 1 (current - employed by University group and then leased to Hospital)

Pros:
Low workload during weekdays given resident help and flexibility to be off site in short notice or pursue other interest (movie, taking lunch date etc). This routinely allows me to catch up on shows on netflix several times a week
More opportunity to do subspeciality thing. Subspeciality: general proportion -- 60:40
It is a part of university based group so has access to governmental 457b and relatively affordable insurance.

Cons:
Coverage is patchy usually I work 2 weekend/month and over last years I have not been able to fully utilize my vacation time. Even when I take vacation, I do end up doing some remote work (usually 1-2 hrs/day).

Salary model with no productivity. My wRVU numbers are greater than 90th percentile and proposed revised pay is around 75th percentile. To increase salary, it took several months of negotiation and it still is not based on a clear mode. That would mean that, as and if I get busier, renegotiation every few years.


Scenario 2 (prospective)


Pros:
Steady coverage given small private group (5 physician and I will be the sixth)
15 month salary, productivity afterwards; keep collection after overhead
One in three weekend expectation.

Cons:
Busier work day given less of subspeciality work and no residents
No salary guarantee and income between partners vary quite a bit. From what I have heard, highest earning partner makes 1.5X times of what I make and lowest earning makes half than what I do. I am not sure where in this wide spectrum I would fall, probably in middle.
I will lose certain amount of subspeciality practice which comes as part of being employed by hospital/system and may not be busy enough like

Given non compete from my previous job, I will have to leave my current practice hospital for 1 year to 30 minutes away location with eventual return to this hospital after 1 year which is doable.

Thank you

[Wricha]

Darkhorse,
Seems to me the question you are asking? Should I continue to work as an employee of a system or go into private practice. A six person group maybe sustainable depending on location, specialty and age of the partners (recruitment issues). Working for a system has its downside but in general they are run by people who are still afraid of physicians which gives you more latitude. Group practices tends to more autocratic (mean the “senior” partner(s) write the rules depending on what stage of life they are in). Staff tends to more responsive in private practice particularly if you are the senior partner. If the wife is the practice manger in the private practice ...run. Again you need to determine if this practice can make it financially as a six person group.

[Olemiss540]

Not a doc, but quick thought.

If you are 90% percentile in productivity at current position, why do you believe you will be middle of the road in your next (productivity based position)?

If I knew I was highly productive, I would probably fight for a productivity based pay scale. This opportunity or the next.

[darkhorse]

Not a doc, but quick thought.

If you are 90% percentile in productivity at current position, why do you believe you will be middle of the road in your next (productivity based position)?

If I knew I was highly productive, I would probably fight for a productivity based pay scale. This opportunity or the next.

Thank you, that is helpful. Part of it has to do with, I enjoy doing certain procedure being hospital employed; I will loose that. I will gain in some other aspects though.

[darkhorse]

Darkhorse,
Seems to me the question you are asking? Should I continue to work as an employee of a system or go into private practice. A six person group maybe sustainable depending on location, specialty and age of the partners (recruitment issues). Working for a system has its downside but in general they are run by people who are still afraid of physicians which gives you more latitude. Group practices tends to more autocratic (mean the “senior” partner(s) write the rules depending on what stage of life they are in). Staff tends to more responsive in private practice particularly if you are the senior partner. If the wife is the practice manger in the private practice ...run. Again you need to determine if this practice can make it financially as a six person group.

Thank you, what should I look for to figure out if this practice can make it financially?

As it turns out wife is playing some role in practice, not sure about the title. It seems to be norm though in my area with at least two other practices I know off which are outside of my field has spouse of founding person working in some capacity


The practice has been around for 20 plus years. Hospital has open staff model so unless that changes or hospital decides to hire their own, it seems sustainable in near future. I have been told that overheads are divided equally and new things are discussed in monthly meeting before implementing changes.

Unfortunately system so far has not invested in my area of specialty in hiring people. Hospital has open staff model. Hospital hired me and they did not do subsequent hiring. I was told that at some point I will get partner to share work load once I am busy enough. I am busy enough and hospital has told me they will look into obtaining per day coverage for my vacation. However, they are not able to give me timeline on when that will happen.

[Olemiss540]

Not a doc, but quick thought.

If you are 90% percentile in productivity at current position, why do you believe you will be middle of the road in your next (productivity based position)?

If I knew I was highly productive, I would probably fight for a productivity based pay scale. This opportunity or the next.

Thank you, that is helpful. Part of it has to do with, I enjoy doing certain procedure being hospital employed; I will loose that. I will gain in some other aspects though.

But with your experience, I would think landing a subspecialty partnership would be only a matter of effort? Congrats on the great career and thanks for your very valuable societal contributions!

[StormShadow]

Of the two options, I would stick with Scenario 1.

Two weekends per month absolutely sucks, but if you have residents there to pre-round I imagine its still relatively light.

Unless your salary is expected to explode in private practice, I would stick with the university job with residents to deal with the scut. I would think you'd be less likely to burn out in that scenario.

Is there an option 3 with community hospital work? Hospital employed, larger guaranteed salary but no residents?

[4nwestsaylng]

I think you need to either stick with scenario 1 or look for more options, including perhaps other places you would be willing to live. Scenario 2 does not sound that great. First, if the highest earner only is 1.5 greater than your current salary, without any resident help, you would be working harder even if you end up with the same salary as you have now. Second, one weekend in three is going to be a much tougher weekend without residents. It will likely be a very full weekend of work, and before you know it, that call weekend is coming up again.

I would not join any group where the wife of the senior partner is doing some of the work, you will never get a fair shake.

Also, if there is a subspecialty area or procedure you like to do, it keeps life interesting, so scenario 1 wins again.

University groups are always less than ideal, there are many issues, including some high dollar specialties subsidizing primary care or someone else's high malpractice premiums. However if you like teaching residents, and they do much of the call it can be pretty good.

Have you considered a VA position? Sometimes you can still get resident coverage, and even at nonteaching hospitals call can be reasonable, and you get federal benefits and a pretty good salary. That would be one option. Some VAs are good, some not so good however.

So I would say stick with the university group, but if you see some issues you are not happy with long term, and are willing to consider relocation, then I would look for a private group that does your subspecialty. I suspect you are internal medicine, if so, doing a high proportion of general internal medicine can be monotonous.

Finally, no matter how much you like your work, look to save and invest and start to think of a target date when you might like to retire and perhaps pursue other interests. Think about whether you want to work twenty more years or thirty. Last time I checked, doctors do not generally outlive patients (ie., they become patients, perhaps with a diagnosis outside their own specialty:) ).

From what you say you like your specialty work, so perhaps the goal should really be to increase the proportion of your time in specialty ideally some day to 100 percent, even if you have to relocate.

Also never forget that no matter what your salary, it is pretax. When you commit more time or intensity to get a higher salary, the government has its hands in your pocket for part of that time/energy increase. You do not get 100 percent of every extra dollar for extra time or productivity. But you have given up that full unit of time. ie.the state taxes your money, but it cannot tax our time. None of us know how much time we have left, but as they say "they ain't makin any more of it" for us.

[desiderium]

Darkhorse,

I would read the current contract carefully for what your coverage obligations are.
Does it say you have to take call 2 weekends a month?
Does it say you have to give up your vacation or take calls/work when you are away?
My reading of your post indicates a salary at 75 percentile and production at the 90th. Are you production based and being paid a low $/wRVU or on salary? If on salary, I would cut back on production--take your vacation, increase appointment times for certain needy follow up patients and just take more time to do a better job. You will be more satisfied and go home earlier. If they are unhappy with access issues etc, there are many solutions.

Organizations love hard-working physicians. Serious question, what are you doing to enable your own problems?

[Wricha]

Darkhorse,
Seems to me the question you are asking? Should I continue to work as an employee of a system or go into private practice. A six person group maybe sustainable depending on location, specialty and age of the partners (recruitment issues). Working for a system has its downside but in general they are run by people who are still afraid of physicians which gives you more latitude. Group practices tends to more autocratic (mean the “senior” partner(s) write the rules depending on what stage of life they are in). Staff tends to more responsive in private practice particularly if you are the senior partner. If the wife is the practice manger in the private practice ...run. Again you need to determine if this practice can make it financially as a six person group.

Thank you, what should I look for to figure out if this practice can make it financially?

As it turns out wife is playing some role in practice, not sure about the title. It seems to be norm though in my area with at least two other practices I know off which are outside of my field has spouse of founding person working in some capacity


The practice has been around for 20 plus years. Hospital has open staff model so unless that changes or hospital decides to hire their own, it seems sustainable in near future. I have been told that overheads are divided equally and new things are discussed in monthly meeting before implementing changes.

Unfortunately system so far has not invested in my area of specialty in hiring people. Hospital has open staff model. Hospital hired me and they did not do subsequent hiring. I was told that at some point I will get partner to share work load once I am busy enough. I am busy enough and hospital has told me they will look into obtaining per day coverage for my vacation. However, they are not able to give me timeline on when that will happen.

Things to look at:
Market size (big city), one hospital/system town, rural etc. The speciality, for example if you were a dermatologist with 6 docs I would think your safe. If your are rheumatologist and the system has employed rheumatologist you might want to rethink this. Number of specialists in your field in the market both employed and private practice. (See if the population can support it). The age of your future partners. Ideally spread out over a wide age range. You don’t want to go into a practice where 5 of the partners are in the 60s you will be stuck building essentially a new practice. Then there is the “buy in” which I think is a waste of money in most cases. You might want to understand overhead rate (fixed and variable) of the group. Is the “salary guarentee” real or do you have to pay it back with future erranings. How many PCPs (your referral source) are employed by system vs private practice. That should get you started

[JPM]

Perhaps seeking option 3 is preferable since neither option described in the OP seems attractive.

The VA suggestion is a very good one if work/life balance is the most important consideration. Workloads are usually relatively light, pay is good if less than in large group or most small private groups, the job is very secure, and the benefits are excellent especially retirement benefits. In IM if your health holds up you can work into your 70s if you like the work. Some of my IM specialist colleagues retired from the VA with a nice pension and healthcare for life and then went into small group private practice. If you were paid by the VA during all or part of your training, it counts on your time in federal service and can allow you to retire after 30 years of service in your 50s. If you have military service in your background that counts too.

Consider a large doctor-friendly group. Pay rates are good, call coverage is good, but they are generally in less desirable locations in terms of weather. Here in the midwest, Cleveland Clinic and Aurora in Wisconsin are probably the most doctor-friendly. The Chicago based groups not so much. Mayo is not bad but its organization limits your freedom of choice in assignment rotations. Wisconsin has several midsize groups: Gundersen, Marshfield, Dean, the University system. Mayo is in northwest Wisconsin and competes with Gundersen.

In other parts of the country, I am not familiar with the degree of doctor-friendliness but the doctors at Intermountain in Utah and Kaiser seem pretty happy as represented in conversations I've struck up at meetings.

Maintaining incomes in a small group has been challenging as new mandates come into force without countervailing fee increases to support them. The changes planned for the payment system may also challenge small IM groups.

In a small IM group, it's important that the group be fair to all. When groups break up, it is usually due to spousal interference, unfair financial arrangements, or differences over the proper balance between commercial and professional values manifest in the group's operations and finances.

When I was in a small private group we had some expenses shared equally, e.g rent and equipment. This was to encourage you to make use of it. We had some expenses shared on a productivity basis, e.g front desk and back office staff. We had some that were direct expenses, e.g your team's MA and/or nurse. That way if you were a small or large producer most of your expenses were proportionate to your production or related to your management of your team. Call was evenly split, no seniority privileges. Everybody worked saturdays. Buy-ins and Buy-outs were cheap, little more than shares of accounts receivable and depreciated value of equipment.

[LadyGeek]

This thread is now in the Personal Finance (Not Investing) forum (career guidance).

[RobLyons]

Personally I would stick with career #1 based off these observations
1. The issues you discussed seem to have been negotiated well on your part, even with no exact time line for the coverage
2. Busier work schedule with no guarantee of higher income
3. The grass is always greener principle


I'm not an MD but in the medical field, and from my observations the MDs that relocate do so usually for
-excellent opportunities
-promotions (open own practice, fellows becoming attendings, etc)
-huge salary increases
and
-preferred location

Maybe readdressing the time off coverage time line in a few months will help you in your current practice.
Best of luck in your career!

[fru-gal]

Not an MD, but I had a job where I was on call always. I burned out pretty fast.

I do not understand why you have to be on call more than one weekend a month and on your vacations. Do I understand that you are so specialized that there is no other doctor who can take these calls? I think you have to say No to this.