Physicians: Should I leave my job?

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Topic Author
S4C5
Posts: 189
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Physicians: Should I leave my job?

Post by S4C5 »

I'm 36 years old and finished residency a little over a year ago and took the highest paying job I could find. I graduated with no debt as I had a side business that earned me around 100k/year throughout medical school and residency. I've done well in terms of making money from work, but not in terms of from investments. I have about $500k in a brokerage account (taxable), $200k in savings, and probably $250k in various retirement plans. I'd like to be out of the game by age 50 and at least partially retired in the Caribbean or Europe or somewhere similar.

For the purposes of anonymity, I won't disclose my specialty here, but I'm in a small subspecialty with a tight job market. Like most subspecialties, the main worries for the future are oversupply driving down revenues and job opportunities and geographic flexibility if I want to make a lateral move.

The job I took was hospital employed in a rural area. I was given a $125k signing bonus (which has been wasting away in a CD at 2.8%), but it's tied to a 5 year forgiveness clause (if I leave before 5 years I have to pay a prorated portion back). My salary is $650k/year with a $70/wRVU conversion factor. In other words, I need around 9300 wRVU per year to make up my salary guarantee and anything beyond that is bonus. I SHOULD be making around 11,000 wRVU per year, which would be around $770k/year income (but I'm not, see below).

Here are the problems with my current position:

1. I am an employee. I heard about the pitfalls of this but had to experience it first-hand to see how badly hospital administrators really treat physicians they employee. I have no control over my clinic. I can't hire and fire insubordinate staff. I can't get the hospital to invest a dime in anything for my patients (even if I can prove it will generate income in the long-term, let alone if it's the right thing for patient care). It's maddening.
2. Income. $650k/year sounds like a lot, but my department bills out probably 1 million a month. I know I am very profitable to the system and make them a lot of money. The wRVU bonus is basically a scam. The hospital is apparently notorious for not paying our this bonus. I tried to audit the records on my own to discover why my wRVU numbers were so low and I discovered that they are not reporting wRVU based on date of service, but to date of billing, which is often months behind. So, for example, if I earned 11,000 wRVU in a calendar year with 2k wRVU in December, but they were a month behind in billing, when the bonus was calculated on January 1, I would only have 9000 wRVU for the year and would not receive a payout. I called them on this scheme and a heated argument ensued. They promised they would tie wRVUs to date of service "for me only," but as this was such an egregious bait-and-switch, I have little faith I will ever receive any wRVU-based production bonus. I have talked to other physicians about how wRVUs are calculated here, and they are appalled. The hospital likes to hire young physicians, and it's obvious why. They want people who are naïve to how the business works.
The benefits are awful. I am maxing out my 403b and 457b (19k/year each), but the company match doesn't start until after 2 years and doesn't fully vest until 5 years later.
3. Location. It's extremely rural. There is nothing here and oddly the cost of living is very high.
4. Lies. The people I work for consistently lie. A great example is that when I signed my contract I was promised a 4 day work week (in writing). When I showed up, they wanted me to work Fridays. As a compromise, I agreed to work Fridays but that I would be allowed to bank 52 Fridays a year as PTO. I now have 82 days a year of PTO total. That's a lot of PTO to try and use (and find locums coverage for), and of course, we aren't compensated for unused PTO. And of course, when I'm gone for weeks at a time, they aren't giving me the wRVUs my clinic is producing. Whereas if I had Fridays off, I wouldn't be doing any work/earning any income on those days anyway since I get it all done in the other 4 days. So basically, I'm losing 52 days a year of wRVU bonus. Those are expensive vacation days. Additionally, being gone that much is bad for continuity of care and I have to spend a lot of time when I get back tidying everything up.

The pros of my current position:
1. Time off/lifestyle. I was enjoying travelling all over the world until COVID hit. Regardless, my job is pretty chill. I show up around 8:30 and can leave by 4 most days. No call and no weekends. No travelling to outreach clinics. However, without being able to travel and having no kids, this is fairly pointless and boring. I'd rather work more and make more money.
2. Income. Even though I feel like I should be making more considering how rural the system is and how much I bill, I still make around the 75th percentile level compared to my peers.

I have realized fairly quickly, the path to success in my field is ownership, which is something very few of us are able to accomplish. Most are employees. However, some are able to buy into private practices and earn incomes around 1-1.5 million. Finding these parternship track positions is difficult, and they typically require 2-3 years of a $300k associate salary.

I have been interviewing and am faced with 4 very different options:
1. Hospital employee in a much better location (a coastal resort area). If I could talk them into letting me invest in the practice as some sort of joint venture, I would be interested. I really want to have some skin in the game and actual potential for higher reward for more work and growing the practice. I'm not sure I want to just keep earning the same salary no matter what I do forever.
2. Private practice in a multispecialty group. All partners regardless of specialty make the same income, which is about what I make now. It's in a city (Minneapolis) instead of a rural area, but the weather is far worse and requires a lot more work, travel, and with less time off. The upside is that I would no longer work directly for the hospital.
3. Starting my own practice. I have been talking to a few other doctors and we see an opportunity in a very rural area near where I am now that is not served. The downsides are much more financial risk and really going off the beaten path, but the upside is that if we had our own practice, we could be collecting the same $1 million/month my current practice is currently turning over to the hospital system.
4. Resign my current position and attempt to negotiate higher pay. At this point, I think it would take a salary guarantee of $800k for me to stay, and I don't see the hospital agreeing to that. And I'm not even sure that's worth all the other B.S.

The two major financial considerations in leaving are the payback of my $125k signing bonus and the fact that I just built a custom $600k house here that is nearing completion and I will have 20% in and may be difficult to sell to re-coup my expenses.

So, should I stick with it here or go with one of the other options above? Word has gotten around that I'm considering leaving and admin has scheduled a meeting with me later this week.
Inframan4712
Posts: 231
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Re: Physicians: Should I leave my job?

Post by Inframan4712 »

Physician here.

Setting aside the bait and switch for a moment.

The grass is always greener.

You work 8-4 with no call and your guaranteed salary is $650k, right? You are at least getting that I assume.

Good for you for buying a house that is less than one year of your gross income.

No call is huge. I switched to a no call position recently and I am a different person. I’m my old self before I went into medicine. I had no idea how tired I was. Don’t ignore this consideration.

You are a new attending. I don’t think it will move the needle for you financially to repay part of the $125k bonus but you may also have to pay tail coverage, which for me was a lot.

I would stick it out for 3-5 years and make administration think I was as happy as can be. Try to make the best of it. Take up hobbies, explore your rural outdoors.

Most importantly, what does your partner or spouse want?
Inframan4712
Posts: 231
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Re: Physicians: Should I leave my job?

Post by Inframan4712 »

Also, if your department is billing 1 million and paying you $650k they may be losing money after salaries for all other staff plus facilities costs.

EDIT: whoops. Per month not year as pointed out down below, thanks.
Last edited by Inframan4712 on Tue Sep 22, 2020 6:43 am, edited 1 time in total.
NeuroDragn
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Re: Physicians: Should I leave my job?

Post by NeuroDragn »

Hey, life is too short to be miserable at work. Especially in your situation, these "highest paying jobs" are well compensated for a reason - because they can't attract help, either the location or the administration or the work characteristics. I think if it were me, I would stay until the end of the 5 year repayment period. In the meantime might as well make it known you are unhappy and negotiate for higher comp. Worse they could say is no, doesn't seem like they have any incentive to somehow terminate you. Whatever your specialty it sounds like it's uncommon and hard to attract. Whatever your next position you are now entering with experience and eyes wide open about what you want and what didn't work well before.

Good luck!
21&lewis
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Re: Physicians: Should I leave my job?

Post by 21&lewis »

Couple thoughts:

1. Employees are never paid what they're worth. That's how employers make $.
2. $650K is a lot of $ for banker's hours and NO call. I'd gladly give up a significant amount of $ to have no call.
3. The pandemic has pumped the brakes on things you enjoy outside of work. That's the same for pretty much everyone, and it won't last forever.
4. Take your signed contract to your meeting later this week and STOP working Fridays as soon as possible. That takes you down to 4 days a week ~8 hours/day for $650K with NO nights NO weekends NO call...that is very difficult to improve upon.
5. Reassess one year after accomplishing #4
Garfieldthecat
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Re: Physicians: Should I leave my job?

Post by Garfieldthecat »

Inframan4712 wrote: Tue Sep 22, 2020 6:19 am Also, if your department is billing 1 million and paying you $650k they may be losing money after salaries for all other staff plus facilities costs.
The $1 million in billing is per month, so $12 Mil/year.
Olemiss540
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Re: Physicians: Should I leave my job?

Post by Olemiss540 »

Sounds like a pretty sweet gig as far as I can see.

I would have a hard time leaving given your income and lifestyle. You will be FI in no time, why risk another position where you may end up working 80 hrs a week plus call??

In terms of bonus structure, wont that even out next year? If it's a few months behind it should normalize after the first year right?
I hold index funds because I do not overestimate my ability to pick stocks OR stock pickers.
Topic Author
S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

Olemiss540 wrote: Tue Sep 22, 2020 6:34 am In terms of bonus structure, wont that even out next year? If it's a few months behind it should normalize after the first year right?
This is what the hospital tried to tell me. The answer is no, for 2 reasons:

#1. If I work very hard one year and earn 12k wRVU @ $70/wRVU. Then I should get $840k. But if they don't count 2k wRVU in December, then I miss out on $120k of income for that year. No sweat you say, I get it next year. Well suppose my business slows down and I only earn 8000 wRVU the next year. And 1000 of that was in December, so they are counting 2k from the prior year and 7k from the current year = 9k wRVU. I don't get any bonus that year, so my $120k has evaporated into the hospital's coffers.
#2. If I leave the 120k on the table, and even if I have a busy year and I get it the next year, then I am losing the time-value of $120k for a full year.

The hospital knows this. It's a dirty trick so that they can average out more busy times and less busy times. wRVU bonuses only make sense when they are set to strict accounting periods. Eventually when you leave the company, say in June of a year and you've got 3000 wRVU hanging in the balance from prior years, they are not going to pay that out because you didn't make it to the end of the year. I'm already anticipating this fight.
Topic Author
S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

Inframan4712 wrote: Tue Sep 22, 2020 6:19 am Also, if your department is billing 1 million and paying you $650k they may be losing money after salaries for all other staff plus facilities costs.

EDIT: whoops. Per month not year as pointed out down below, thanks.
It's really difficult to complain about a $650k salary, but the reality of the billing is correct. The potential upside is huge for going out on my own to at least double that or more, and more importantly, be in charge of my own business. Of course there is the risk we couldn't make it and be stuck with the debt as well, but that's fairly unheard of in this business. Worst case, I'd still be profitable but making less than I do now with more stress of running the business. But I'm entrepreneurial minded and like the idea of building something and making my own way.

I'm not sure I'll have an option to go out on my own again like this. It's becoming harder and harder to do it and find good partners willing to start something.
potatopancake
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Re: Physicians: Should I leave my job?

Post by potatopancake »

How expensive will it be to go out on your own? I would seriously consider it. You will be your own boss. No partnership track. You have done very well already and are willing to take high-paying, rural jobs which are not going away.
Topic Author
S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

Inframan4712 wrote: Tue Sep 22, 2020 6:17 am I would stick it out for 3-5 years and make administration think I was as happy as can be. Try to make the best of it. Take up hobbies, explore your rural outdoors.
Financially, sticking it out 5 years is the safe and smart move. I know that. I can save aggressively, will have the $125k signing bonus pocketed, and will have maxed out 38k/year of tax-advantaged accounts and be fully vested with the hospital's 19k/year match.

However, at that point I will be 40 years old. I can already feel my youth evaporating and wasting away out here in literally the middle of nowhere. I started medical school exactly 10 years ago and it seems like yesterday. I missed those years. How long do I keep delaying gratification? The thoughts in my head are whether it's worth it to take much less money and move to a more invigorating place. Or, if I am going to stay out here, then why not take the risk and try it on my own as I've got no dependents and no debt? I know people who've done it and are making 3+ mil/year. They are <1% of physicians in the field, but it can be done if one is bold and motivated.
Inframan4712
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Re: Physicians: Should I leave my job?

Post by Inframan4712 »

S4C5 wrote: Tue Sep 22, 2020 7:11 am
Inframan4712 wrote: Tue Sep 22, 2020 6:17 am I would stick it out for 3-5 years and make administration think I was as happy as can be. Try to make the best of it. Take up hobbies, explore your rural outdoors.
Financially, sticking it out 5 years is the safe and smart move. I know that. I can save aggressively, will have the $125k signing bonus pocketed, and will have maxed out 38k/year of tax-advantaged accounts and be fully vested with the hospital's 19k/year match.

However, at that point I will be 40 years old. I can already feel my youth evaporating and wasting away out here in literally the middle of nowhere. I started medical school exactly 10 years ago and it seems like yesterday. I missed those years. How long do I keep delaying gratification? The thoughts in my head are whether it's worth it to take much less money and move to a more invigorating place. Or, if I am going to stay out here, then why not take the risk and try it on my own as I've got no dependents and no debt? I know people who've done it and are making 3+ mil/year. They are <1% of physicians in the field, but it can be done if one is bold and motivated.
You know yourself best. You’re probably right that you won’t have the energy when you’re older.

If you want to grab for the brass ring now while you’re young and motivated, and if there is a real opportunity, go for it. At least you won’t wonder for the rest of your life if you could have done it.

Just keep your eyes open and be aware of the risks. I know plenty of surgeons for example that bought into ambulatory surgery centers, struggled and worked hard for years, and then gave up and sold to their local hospital. It was a lot of work for not much reward.
Olemiss540
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Re: Physicians: Should I leave my job?

Post by Olemiss540 »

S4C5 wrote: Tue Sep 22, 2020 6:46 am
Olemiss540 wrote: Tue Sep 22, 2020 6:34 am In terms of bonus structure, wont that even out next year? If it's a few months behind it should normalize after the first year right?
This is what the hospital tried to tell me. The answer is no, for 2 reasons:

#1. If I work very hard one year and earn 12k wRVU @ $70/wRVU. Then I should get $840k. But if they don't count 2k wRVU in December, then I miss out on $120k of income for that year. No sweat you say, I get it next year. Well suppose my business slows down and I only earn 8000 wRVU the next year. And 1000 of that was in December, so they are counting 2k from the prior year and 7k from the current year = 9k wRVU. I don't get any bonus that year, so my $120k has evaporated into the hospital's coffers.
#2. If I leave the 120k on the table, and even if I have a busy year and I get it the next year, then I am losing the time-value of $120k for a full year.

The hospital knows this. It's a dirty trick so that they can average out more busy times and less busy times. wRVU bonuses only make sense when they are set to strict accounting periods. Eventually when you leave the company, say in June of a year and you've got 3000 wRVU hanging in the balance from prior years, they are not going to pay that out because you didn't make it to the end of the year. I'm already anticipating this fight.
No, the $120k was eaten up due to you having a slow year yet still getting paid your full base pay. I dont think you will find many options for hospital admin that will make you happy even in a partnership situation.

Stick it out until you can afford the risk of going out on your own. Then you will work twice as hard (goodbye vacations) but atleast you will get the fruits of your own labor. You seem like the type best suited for solo practice but beware there will be new things that you will be dealing with that will drive you crazy.
I hold index funds because I do not overestimate my ability to pick stocks OR stock pickers.
Old Sage(brush)
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Re: Physicians: Should I leave my job?

Post by Old Sage(brush) »

I agree with other comments, this sounds pretty good. Also agree if you’re truly miserable time to make a change although you may have to stick it out to figure it out. Regarding problem number 4, the lying, apparently that’s just what people do now and it is ok. Until people begin to call others on it, in the workplace and other places that are important lying will just become the norm, what everyone does. When people in leadership positions lie it creates HUGE problems as you note.
toocold
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Re: Physicians: Should I leave my job?

Post by toocold »

Are you sure the hospital bills you out at $12M? Most treatments are a combination of professional fees and facility fees, and just looking at a recent bill, it's almost 1:10. Most health systems actually lose money on the professional side but make it up on the facility side. Before you pursue your own practice, you should understand the economics better.

If you are unhappy, I would find another position. It's a fact that rural settings pay more. I personally would take a paycut to live in an area that I like.
fourwheelcycle
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Re: Physicians: Should I leave my job?

Post by fourwheelcycle »

S4C5 wrote: Tue Sep 22, 2020 5:07 am I'm 36 years old and finished residency a little over a year ago ..... the path to success in my field is ownership .... some are able to buy into private practices ..... Finding these partnership track positions is difficult, and they typically require 2-3 years of a $300k associate salary.
I am not a physician, but I worked closely with physicians for my whole career, including listening to their job concerns and watching them work through the same options you are considering.

You are just starting out. As you are already learning, every work setting has its risks and rewards. You have suggested finding a partnership opportunity could be good. Let me assure you, many young docs have jumped from hospital or large, multispecialty group practice jobs to seemingly attractive partnership opportunities where the senior partners took advantage of them in terms of hours, workdays, and pay surprises that sound just like your hospital complaints. Worse yet, once you get in a practice where you are the junior doc, with one or a few senior partners, you can find that poor practice management, divorce fights, or just plain old ornery eccentricities on the part of the senior partners can make your life miserable. Hopefully, this will not happen, but be aware that it can, and it can be hard to anticipate or discern these problems when you are focused on getting away from what you already consider to be a bad situation.

You are very fortunate to be well trained, with many opportunities ahead of you. I have admired docs who remained in rural communities, where they were clearly needed and appreciated. I have also admired docs who were in bad situations and finally took the initiative to move on, hopefully to better situations. You need to find the balance of patient care, personal life and interests, and work setting and income that is best for you. My advice is to develop an outlook where you aim to be happy and make the best contribution you can, whether in your current position or your next one. Do not focus on unfairness around you, and do not let that unfairness make you cynical or insensitive to the impact of your own attitudes and actions on others, at work or at home. Skills you may learn in being happy, helpful, and diplomatic with others, even in stressful, unfair circumstances, will serve you well throughout your life and your career.
coffeeblack
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Re: Physicians: Should I leave my job?

Post by coffeeblack »

S4C5 wrote: Tue Sep 22, 2020 7:00 am
Inframan4712 wrote: Tue Sep 22, 2020 6:19 am Also, if your department is billing 1 million and paying you $650k they may be losing money after salaries for all other staff plus facilities costs.

EDIT: whoops. Per month not year as pointed out down below, thanks.
It's really difficult to complain about a $650k salary, but the reality of the billing is correct. The potential upside is huge for going out on my own to at least double that or more, and more importantly, be in charge of my own business. Of course there is the risk we couldn't make it and be stuck with the debt as well, but that's fairly unheard of in this business. Worst case, I'd still be profitable but making less than I do now with more stress of running the business. But I'm entrepreneurial minded and like the idea of building something and making my own way.

I'm not sure I'll have an option to go out on my own again like this. It's becoming harder and harder to do it and find good partners willing to start something.
650K is a great salary. Especially with those hours.
When you start your practice you have to understand and accept that you will go in the hole for a while. That is the nature of business due to the start up costs and the time it takes to build up your business.

There is an opportunity cost.

With that said, as you have mentioned there is a potential to make more because you keep more even after the overhead as long as you run your practice efficiently and get the patients. You stated it is fairly unheard of in your specialty that you won't make it. So if that is accurate then you are in a good position.

However, you also said you are and entrepreneurial person. I don't think that is actually correct. I think you are wanta preneurial. I'm not saying this to put you down. I"m observing your behavior. You chose to take a job instead of go on your own. I get that it was a well paying job but it was still a job. So you chose the easy and fast way. And that's fine. It's 650K per year but now you feel it's not for you and you are really and entrepreneurial minded person. If that is true, then you will do you homework on opening a practice and get on with it because that's what entrepreneurial minded people do. I'm not saying you should do this. I'm just talking about behavior patterns. It may seem like I'm splitting hairs. I'm not. You gave yourself 4 options. You are going on interviews. You are trying to figure out if you are an entrepreneur. The decision you make will have lasting effects on the next 15 to 20 years of your life and career.

Opening a practice is the hard way but can be rewarding (at least financially) in the end. Now, you feel the administration is not being fair to you. They won't be fair to you. They want to make money off of you. To them a 650K salary is fair. Many would argue it is.

You will be an entrepreneur when you start you practice and grind it out. If you want to do that, accept that you will go into debt and that 650K will disappear until you build your practice.
Wricha
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Re: Physicians: Should I leave my job?

Post by Wricha »

I am not a physician so you can disqualify my advice. However, I have built many multi specialty group practices from the ground up to very large practices and sold them to hospital systems, insurance companies and merged them with other groups. In short, I have bought/sold hundreds of practice and dealt many physicians and associated problems. The last few statements are for context only not to say what a wonderful boy am I.

1. No one and I mean no one can screws a physician like a senior partner in private practice. It will make your administrators look like Mr Rogers
2. You choose a rural setting (for the money) did you really think the administration there was going to top tier/sophisticated?
3. Just reading your post and the days off deal, tells me they (administrators) are clueless (in your favor) .
4. Everyone is lying suggests to me that you need to do an internal assessment of oneself. Rarely does everyone one lie. Instead people may be avoiding you because you may have come on to strong with your injustices and requirements.
5. Get over the fact that you make the hospital a lot of money. You are a part of big organization that has a huge responsibility to its community. Nurses, cleaning staff, and support folks don’t bring in a dime any yet without them you could not function.
6. Starting a private practice maybe the answer for you but be prepared for some lean years initially and a big learning curve.
7. Another healthcare system maybe better but given what I have read, doubtful.
8. You choose security and you wanted riches they seldom go together
coffeeblack
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Re: Physicians: Should I leave my job?

Post by coffeeblack »

Wricha wrote: Tue Sep 22, 2020 8:26 am I am not a physician so you can disqualify my advice. However, I have built many multi specialty group practices from the ground up to very large practices and sold them to hospital systems, insurance companies and merged them with other groups. In short, I have bought/sold hundreds of practice and dealt many physicians and associated problems. The last few statements are for context only not to say what a wonderful boy am I.

1. No one and I mean no one can screws a physician like a senior partner in private practice. It will make your administrators look like Mr Rogers
2. You choose a rural setting (for the money) did you really think the administration there was going to top tier/sophisticated?
3. Just reading your post and the days off deal, tells me they (administrators) are clueless (in your favor) .
4. Everyone is lying suggests to me that you need to do an internal assessment of oneself. Rarely does everyone one lie. Instead people may be avoiding you because you may have come on to strong with your injustices and requirements.
5. Get over the fact that you make the hospital a lot of money. You are a part of big organization that has a huge responsibility to its community. Nurses, cleaning staff, and support folks don’t bring in a dime any yet without them you could not function.
6. Starting a private practice maybe the answer for you but be prepared for some lean years initially and a big learning curve.
7. Another healthcare system maybe better but given what I have read, doubtful.
8. You choose security and you wanted riches they seldom go together
I like this post.
I don't know if I fully agree with 5. He could function without the hospital. All doctors could function without the administration. Doctors can still treat the patients without all the middlemen. They will need the nurses and cleaning staff etc. They are important. Administrators have become way to important.
Number 4 has to do with communication and negotiation skill or lack of them or lack of desire to have them and perform them.

I think the OP needs to first communicate to himself what he really wants. He is young and new to the game. In many ways it's a good place to be.
flyfishers83
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Re: Physicians: Should I leave my job?

Post by flyfishers83 »

How much is enough? You're saying you can work less than 40 hours per week and make 700k+. Those gigs would seem to be few and far between. Is your goal to earn the most money or is to earn a LOT of money and have your entire life to spend doing whatever you want with a relaxed schedule. Assuming you're saving more than 300k per year, you'll probably have a net worth greater than 2.5 million at age 40.

If you can get to 4 days a week, you have gained back a tremendous amount of time over your life. If you really want to make more money, I bet you could turn some of these 3 day weekends into a hefty paycheck--with the benefit being you deciding when you work. Alternatively, negotiate for a payout of your unused PTO. That will be a big number.

Financials aside, I'd focus on the location and lifestyle if you're really concerned. Wife and I are somewhat similar (though make a lot less), living in a rural area without quick access to some things we enjoy. 5 years in, it's not a huge hurdle as the cost of living and pay differential means we can afford to go anywhere and do anything whenever we want. You say you like to travel a lot--that's easy on a light schedule. Harder when you have a lot call. Harder still when you're the owner and trying to build something. We have a lot of friends that are similar age to you that have a very hard time taking, or refuse to take, vacation because they know how much they won't be making for that week. Same thing with kids. 30-40 hours per week means lots of time available for kids. 60+ hours with lots of call means significantly less.
oldfort
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Re: Physicians: Should I leave my job?

Post by oldfort »

S4C5 wrote: Tue Sep 22, 2020 5:07 am
2. Private practice in a multispecialty group. All partners regardless of specialty make the same income, which is about what I make now. It's in a city (Minneapolis) instead of a rural area, but the weather is far worse and requires a lot more work, travel, and with less time off. The upside is that I would no longer work directly for the hospital.
Not a physician, but option #2 sounds like an objectively worse job than what you have now, unless you really want to move to Minneapolis: far worse weather, more work, more travel, and less time off for the same pay and no potential in income growth.
Last edited by oldfort on Tue Sep 22, 2020 8:55 am, edited 1 time in total.
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Re: Physicians: Should I leave my job?

Post by White Coat Investor »

S4C5 wrote: Tue Sep 22, 2020 5:07 am I'm 36 years old and finished residency a little over a year ago and took the highest paying job I could find. I graduated with no debt as I had a side business that earned me around 100k/year throughout medical school and residency. I've done well in terms of making money from work, but not in terms of from investments. I have about $500k in a brokerage account (taxable), $200k in savings, and probably $250k in various retirement plans. I'd like to be out of the game by age 50 and at least partially retired in the Caribbean or Europe or somewhere similar.

For the purposes of anonymity, I won't disclose my specialty here, but I'm in a small subspecialty with a tight job market. Like most subspecialties, the main worries for the future are oversupply driving down revenues and job opportunities and geographic flexibility if I want to make a lateral move.

The job I took was hospital employed in a rural area. I was given a $125k signing bonus (which has been wasting away in a CD at 2.8%), but it's tied to a 5 year forgiveness clause (if I leave before 5 years I have to pay a prorated portion back). My salary is $650k/year with a $70/wRVU conversion factor. In other words, I need around 9300 wRVU per year to make up my salary guarantee and anything beyond that is bonus. I SHOULD be making around 11,000 wRVU per year, which would be around $770k/year income (but I'm not, see below).

Here are the problems with my current position:

1. I am an employee. I heard about the pitfalls of this but had to experience it first-hand to see how badly hospital administrators really treat physicians they employee. I have no control over my clinic. I can't hire and fire insubordinate staff. I can't get the hospital to invest a dime in anything for my patients (even if I can prove it will generate income in the long-term, let alone if it's the right thing for patient care). It's maddening.
2. Income. $650k/year sounds like a lot, but my department bills out probably 1 million a month. I know I am very profitable to the system and make them a lot of money. The wRVU bonus is basically a scam. The hospital is apparently notorious for not paying our this bonus. I tried to audit the records on my own to discover why my wRVU numbers were so low and I discovered that they are not reporting wRVU based on date of service, but to date of billing, which is often months behind. So, for example, if I earned 11,000 wRVU in a calendar year with 2k wRVU in December, but they were a month behind in billing, when the bonus was calculated on January 1, I would only have 9000 wRVU for the year and would not receive a payout. I called them on this scheme and a heated argument ensued. They promised they would tie wRVUs to date of service "for me only," but as this was such an egregious bait-and-switch, I have little faith I will ever receive any wRVU-based production bonus. I have talked to other physicians about how wRVUs are calculated here, and they are appalled. The hospital likes to hire young physicians, and it's obvious why. They want people who are naïve to how the business works.
The benefits are awful. I am maxing out my 403b and 457b (19k/year each), but the company match doesn't start until after 2 years and doesn't fully vest until 5 years later.
3. Location. It's extremely rural. There is nothing here and oddly the cost of living is very high.
4. Lies. The people I work for consistently lie. A great example is that when I signed my contract I was promised a 4 day work week (in writing). When I showed up, they wanted me to work Fridays. As a compromise, I agreed to work Fridays but that I would be allowed to bank 52 Fridays a year as PTO. I now have 82 days a year of PTO total. That's a lot of PTO to try and use (and find locums coverage for), and of course, we aren't compensated for unused PTO. And of course, when I'm gone for weeks at a time, they aren't giving me the wRVUs my clinic is producing. Whereas if I had Fridays off, I wouldn't be doing any work/earning any income on those days anyway since I get it all done in the other 4 days. So basically, I'm losing 52 days a year of wRVU bonus. Those are expensive vacation days. Additionally, being gone that much is bad for continuity of care and I have to spend a lot of time when I get back tidying everything up.

The pros of my current position:
1. Time off/lifestyle. I was enjoying travelling all over the world until COVID hit. Regardless, my job is pretty chill. I show up around 8:30 and can leave by 4 most days. No call and no weekends. No travelling to outreach clinics. However, without being able to travel and having no kids, this is fairly pointless and boring. I'd rather work more and make more money.
2. Income. Even though I feel like I should be making more considering how rural the system is and how much I bill, I still make around the 75th percentile level compared to my peers.

I have realized fairly quickly, the path to success in my field is ownership, which is something very few of us are able to accomplish. Most are employees. However, some are able to buy into private practices and earn incomes around 1-1.5 million. Finding these parternship track positions is difficult, and they typically require 2-3 years of a $300k associate salary.

I have been interviewing and am faced with 4 very different options:
1. Hospital employee in a much better location (a coastal resort area). If I could talk them into letting me invest in the practice as some sort of joint venture, I would be interested. I really want to have some skin in the game and actual potential for higher reward for more work and growing the practice. I'm not sure I want to just keep earning the same salary no matter what I do forever.
2. Private practice in a multispecialty group. All partners regardless of specialty make the same income, which is about what I make now. It's in a city (Minneapolis) instead of a rural area, but the weather is far worse and requires a lot more work, travel, and with less time off. The upside is that I would no longer work directly for the hospital.
3. Starting my own practice. I have been talking to a few other doctors and we see an opportunity in a very rural area near where I am now that is not served. The downsides are much more financial risk and really going off the beaten path, but the upside is that if we had our own practice, we could be collecting the same $1 million/month my current practice is currently turning over to the hospital system.
4. Resign my current position and attempt to negotiate higher pay. At this point, I think it would take a salary guarantee of $800k for me to stay, and I don't see the hospital agreeing to that. And I'm not even sure that's worth all the other B.S.

The two major financial considerations in leaving are the payback of my $125k signing bonus and the fact that I just built a custom $600k house here that is nearing completion and I will have 20% in and may be difficult to sell to re-coup my expenses.

So, should I stick with it here or go with one of the other options above? Word has gotten around that I'm considering leaving and admin has scheduled a meeting with me later this week.
I wouldn't work for or with someone that lied to me. The truth is you're going to be financially fine no matter what you do. I mean, you're already a millionaire with an income of $650K and you want to work 14 more years. You don't have to keep this job to be successful. About 50% of docs switch jobs in their first 1-2 years. You should have waited to buy the house until you were sure you liked the job, but that's water under the bridge now. Hopefully you don't have much trouble selling it.

Personally, I like being an owner, so I'd only consider 2 and 3. You can afford to take the risks associated with # 3, so I would, again assuming you're okay with a rural life.
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Re: Physicians: Should I leave my job?

Post by S4C5 »

Olemiss540 wrote: Tue Sep 22, 2020 7:30 am
S4C5 wrote: Tue Sep 22, 2020 6:46 am
Olemiss540 wrote: Tue Sep 22, 2020 6:34 am In terms of bonus structure, wont that even out next year? If it's a few months behind it should normalize after the first year right?
This is what the hospital tried to tell me. The answer is no, for 2 reasons:

#1. If I work very hard one year and earn 12k wRVU @ $70/wRVU. Then I should get $840k. But if they don't count 2k wRVU in December, then I miss out on $120k of income for that year. No sweat you say, I get it next year. Well suppose my business slows down and I only earn 8000 wRVU the next year. And 1000 of that was in December, so they are counting 2k from the prior year and 7k from the current year = 9k wRVU. I don't get any bonus that year, so my $120k has evaporated into the hospital's coffers.
#2. If I leave the 120k on the table, and even if I have a busy year and I get it the next year, then I am losing the time-value of $120k for a full year.

The hospital knows this. It's a dirty trick so that they can average out more busy times and less busy times. wRVU bonuses only make sense when they are set to strict accounting periods. Eventually when you leave the company, say in June of a year and you've got 3000 wRVU hanging in the balance from prior years, they are not going to pay that out because you didn't make it to the end of the year. I'm already anticipating this fight.
No, the $120k was eaten up due to you having a slow year yet still getting paid your full base pay. I dont think you will find many options for hospital admin that will make you happy even in a partnership situation.

Stick it out until you can afford the risk of going out on your own. Then you will work twice as hard (goodbye vacations) but atleast you will get the fruits of your own labor. You seem like the type best suited for solo practice but beware there will be new things that you will be dealing with that will drive you crazy.
Hey you must work for my hospital! Haha.

No, that's not how this arrangement works. The compensation includes a salary guarantee, which means that if you don't produce enough during a year, you still get a minimum salary. This is a perk and part of how the hospital recruits talent. An unused bonus from a prior year is not supposed to be used to make up any future deficits. The only way this makes any sense if there are rigidly fixed accounting periods, be it annually, quarterly, monthly, whatever.

Because of the way the hospital system shifts accounting periods, the wRVU bonus is the proverbial carrot on a stick. You are never going to get what you earned in a calendar year. Multiple physicians here have figured this out and quit, and most business saavy physicians will immediately see the problem with this scheme. Reputable hospitals do not do this and account for wRVU in a timely manner and tie them to date of service, not date of billing.
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Re: Physicians: Should I leave my job?

Post by oldfort »

S4C5 wrote: Tue Sep 22, 2020 5:07 am
3. Location. It's extremely rural. There is nothing here and oddly the cost of living is very high.

3. Starting my own practice. I have been talking to a few other doctors and we see an opportunity in a very rural area near where I am now that is not served. The downsides are much more financial risk and really going off the beaten path, but the upside is that if we had our own practice, we could be collecting the same $1 million/month my current practice is currently turning over to the hospital system.
Based on what you wrote here, I don't see option #3 making you happy in the long run. If you hate your current location because it's too rural, then moving to another very rural area is not a solution.
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Re: Physicians: Should I leave my job?

Post by S4C5 »

flyfishers83 wrote: Tue Sep 22, 2020 8:46 am Assuming you're saving more than 300k per year
That's a pretty hefty assumption when the after-tax income is $360k/year. I think I live frugally, but dang. I'm probably close.
Sometimes I wonder what I'm doing wrong when I see these other posts from physicians only a few years older than me who have multimillion dollar portfolios, lower incomes, AND have paid off student loans that I didn't have! I thought I was doing well until I started browsing these forums!
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Re: Physicians: Should I leave my job?

Post by S4C5 »

coffeeblack wrote: Tue Sep 22, 2020 8:41 am
I don't know if I fully agree with 5. He could function without the hospital. All doctors could function without the administration. Doctors can still treat the patients without all the middlemen. They will need the nurses and cleaning staff etc. They are important. Administrators have become way to important.
Correct. Hospitals are horribly inefficient organizations with enormous administrative bloat, and physicians support that unnecessary administrative pay!

I'm not a fan of hospital administrators, if you can't tell!
Last edited by S4C5 on Tue Sep 22, 2020 3:15 pm, edited 2 times in total.
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Re: Physicians: Should I leave my job?

Post by dodecahedron »

toocold wrote: Tue Sep 22, 2020 7:49 am Are you sure the hospital bills you out at $12M? Most treatments are a combination of professional fees and facility fees, and just looking at a recent bill, it's almost 1:10. Most health systems actually lose money on the professional side but make it up on the facility side. Before you pursue your own practice, you should understand the economics better.
I agree that you need to understand the economics better.

The hospital might be "billing you out" at $12M but the amount they actually *receive* from third party insurers is typically a small fraction of what they bill. Typical bills have unrealistically high and inflated "sticker prices" that essentially nobody pays. Then you have the uninsured patients with little or no assets. It does not matter what you bill them because you can't get blood from a stone.

With the economy the way it is, tens of millions of people have lost jobs and the health insurance coverage that went along with it. Even many small businesses that are struggling to keep folks on the payroll are talking about ending employee health care benefits. Insurance companies may respond by driving tougher and tougher bargains with providers.

Also, we do not know your medical specialty but keep in mind that medical breakthroughs could make you obsolete. (Think of all the docs in the 1950s who specialized in treating polio and TB.)
Last edited by dodecahedron on Tue Sep 22, 2020 9:06 am, edited 1 time in total.
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Re: Physicians: Should I leave my job?

Post by Old Sage(brush) »

Wricha wrote: Tue Sep 22, 2020 8:26 am I am not a physician so you can disqualify my advice. However, I have built many multi specialty group practices from the ground up to very large practices and sold them to hospital systems, insurance companies and merged them with other groups. In short, I have bought/sold hundreds of practice and dealt many physicians and associated problems. The last few statements are for context only not to say what a wonderful boy am I.

1. No one and I mean no one can screws a physician like a senior partner in private practice. It will make your administrators look like Mr Rogers
2. You choose a rural setting (for the money) did you really think the administration there was going to top tier/sophisticated?
3. Just reading your post and the days off deal, tells me they (administrators) are clueless (in your favor) .
4. Everyone is lying suggests to me that you need to do an internal assessment of oneself. Rarely does everyone one lie. Instead people may be avoiding you because you may have come on to strong with your injustices and requirements.
5. Get over the fact that you make the hospital a lot of money. You are a part of big organization that has a huge responsibility to its community. Nurses, cleaning staff, and support folks don’t bring in a dime any yet without them you could not function.
6. Starting a private practice maybe the answer for you but be prepared for some lean years initially and a big learning curve.
7. Another healthcare system maybe better but given what I have read, doubtful.
8. You choose security and you wanted riches they seldom go together
Regarding comment 4, the OP did not say that "everyone is lying". So while I agree with the OP that lying is a big problem, I don't agree that OP needs to do an internal assessment because he was misquoted here.
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Re: Physicians: Should I leave my job?

Post by S4C5 »

dodecahedron wrote: Tue Sep 22, 2020 9:06 am
toocold wrote: Tue Sep 22, 2020 7:49 am Are you sure the hospital bills you out at $12M? Most treatments are a combination of professional fees and facility fees, and just looking at a recent bill, it's almost 1:10. Most health systems actually lose money on the professional side but make it up on the facility side. Before you pursue your own practice, you should understand the economics better.
I agree that you need to understand the economics better.

The hospital might be "billing you out" at $12M but the amount they actually *receive* from third party insurers is typically a small fraction of what they bill. Typical bills have unrealistically high and inflated "sticker prices" that essentially nobody pays. Then you have the uninsured patients with little or no assets. It does not matter what you bill them because you can't get blood from a stone.

With the economy the way it is, tens of millions of people have lost jobs and the health insurance coverage that went along with it. Even many small businesses that are struggling to keep folks on the payroll are talking about ending employee health care benefits. Insurance companies may respond by driving tougher and tougher bargains with providers.

Also, we do not know your medical specialty but keep in mind that medical breakthroughs could make you obsolete. (Think of all the docs in the 1950s who specialized in treating polio and TB.)
I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
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Re: Physicians: Should I leave my job?

Post by newyorker »

I am in a different field but did rural for 4 years. Made similar to what you made but it wasnt worth it. Try rural for 2 more years and see if you can do it for the rest of your life. Reassess your plan then.
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Re: Physicians: Should I leave my job?

Post by stoptothink »

S4C5 wrote: Tue Sep 22, 2020 9:01 am
flyfishers83 wrote: Tue Sep 22, 2020 8:46 am Assuming you're saving more than 300k per year
Sometimes I wonder what I'm doing wrong when I see these other posts from physicians only a few years older than me who have multimillion dollar portfolios, lower incomes, AND have paid off student loans that I didn't have! I thought I was doing well until I started browsing these forums!
They started earlier, period. I am not a physician, but I work in an environment where many of my colleagues are physicians and I sit on the board of my company's medical clinics. And, I get the honor of consistently having my star employees leave me for med school (6 in the last 4yrs). Yes, there are some physicians who are "ahead" of you, but you are absolutely killing it (financially). If used this board to determine my financial status, I'd think I was earning less than half of what I should for my job and was a total financial failure. In reality I earn above the national median for my job, and am above 90th percentile for income and 95th for net worth for my age.
Last edited by stoptothink on Tue Sep 22, 2020 9:19 am, edited 1 time in total.
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Re: Physicians: Should I leave my job?

Post by Wricha »

coffeeblack wrote: Tue Sep 22, 2020 8:41 am
Wricha wrote: Tue Sep 22, 2020 8:26 am I am not a physician so you can disqualify my advice. However, I have built many multi specialty group practices from the ground up to very large practices and sold them to hospital systems, insurance companies and merged them with other groups. In short, I have bought/sold hundreds of practice and dealt many physicians and associated problems. The last few statements are for context only not to say what a wonderful boy am I.

1. No one and I mean no one can screws a physician like a senior partner in private practice. It will make your administrators look like Mr Rogers
2. You choose a rural setting (for the money) did you really think the administration there was going to top tier/sophisticated?
3. Just reading your post and the days off deal, tells me they (administrators) are clueless (in your favor) .
4. Everyone is lying suggests to me that you need to do an internal assessment of oneself. Rarely does everyone one lie. Instead people may be avoiding you because you may have come on to strong with your injustices and requirements.
5. Get over the fact that you make the hospital a lot of money. You are a part of big organization that has a huge responsibility to its community. Nurses, cleaning staff, and support folks don’t bring in a dime any yet without them you could not function.
6. Starting a private practice maybe the answer for you but be prepared for some lean years initially and a big learning curve.
7. Another healthcare system maybe better but given what I have read, doubtful.
8. You choose security and you wanted riches they seldom go together
I like this post.
I don't know if I fully agree with 5. He could function without the hospital. All doctors could function without the administration. Doctors can still treat the patients without all the middlemen. They will need the nurses and cleaning staff etc. They are important. Administrators have become way to important.
Number 4 has to do with communication and negotiation skill or lack of them or lack of desire to have them and perform them.

I think the OP needs to first communicate to himself what he really wants. He is young and new to the game. In many ways it's a good place to be.
I don’t know his specialty (maybe he could) function without a hospital. I just don’t know. My point was he joined an organization who’s mission is much bigger than his speciality. And if he wants to make it there he must see a bigger picture or be extremely unhappy.
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Re: Physicians: Should I leave my job?

Post by flyfishers83 »

S4C5 wrote: Tue Sep 22, 2020 9:01 am
flyfishers83 wrote: Tue Sep 22, 2020 8:46 am Assuming you're saving more than 300k per year
That's a pretty hefty assumption when the after-tax income is $360k/year. I think I live frugally, but dang. I'm probably close.
Sometimes I wonder what I'm doing wrong when I see these other posts from physicians only a few years older than me who have multimillion dollar portfolios, lower incomes, AND have paid off student loans that I didn't have! I thought I was doing well until I started browsing these forums!
OK. So maybe you spend 160k/yr. That's still saving 200k/yr which puts you at 2 million NW at 40 with no investment gains. You're doing phenomenally well. There are so many of your colleagues that will never catch you financially. They'll pay be paying student loans for 20 years and spending like crazy.
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Re: Physicians: Should I leave my job?

Post by coffeeblack »

Wricha wrote: Tue Sep 22, 2020 9:19 am
coffeeblack wrote: Tue Sep 22, 2020 8:41 am
Wricha wrote: Tue Sep 22, 2020 8:26 am I am not a physician so you can disqualify my advice. However, I have built many multi specialty group practices from the ground up to very large practices and sold them to hospital systems, insurance companies and merged them with other groups. In short, I have bought/sold hundreds of practice and dealt many physicians and associated problems. The last few statements are for context only not to say what a wonderful boy am I.

1. No one and I mean no one can screws a physician like a senior partner in private practice. It will make your administrators look like Mr Rogers
2. You choose a rural setting (for the money) did you really think the administration there was going to top tier/sophisticated?
3. Just reading your post and the days off deal, tells me they (administrators) are clueless (in your favor) .
4. Everyone is lying suggests to me that you need to do an internal assessment of oneself. Rarely does everyone one lie. Instead people may be avoiding you because you may have come on to strong with your injustices and requirements.
5. Get over the fact that you make the hospital a lot of money. You are a part of big organization that has a huge responsibility to its community. Nurses, cleaning staff, and support folks don’t bring in a dime any yet without them you could not function.
6. Starting a private practice maybe the answer for you but be prepared for some lean years initially and a big learning curve.
7. Another healthcare system maybe better but given what I have read, doubtful.
8. You choose security and you wanted riches they seldom go together
I like this post.
I don't know if I fully agree with 5. He could function without the hospital. All doctors could function without the administration. Doctors can still treat the patients without all the middlemen. They will need the nurses and cleaning staff etc. They are important. Administrators have become way to important.
Number 4 has to do with communication and negotiation skill or lack of them or lack of desire to have them and perform them.

I think the OP needs to first communicate to himself what he really wants. He is young and new to the game. In many ways it's a good place to be.
I don’t know his specialty (maybe he could) function without a hospital. I just don’t know. My point was he joined an organization who’s mission is much bigger than his speciality. And if he wants to make it there he must see a bigger picture or be extremely unhappy.
Agreed. I believe as long as he is an employee and does not come to terms with what that means, he will be unhappy.
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Re: Physicians: Should I leave my job?

Post by dodecahedron »

S4C5 wrote: Tue Sep 22, 2020 9:08 am I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
If you are aware of the payor mix and billing to collection ratio, then I am sure the third-party payors are also very much aware. And they are likely to drive harder bargains in these exceptionally troubled times when they negotiate reimbursement rates. With GDP declining and financial uncertainty looming, the extreme amounts (by international standards) that Americans have paid for health care in recent years may very well be unsustainable.

As the grand-daughter of a physician who did his residency in the late 1920s, then practiced during the Great Depression (and then volunteered for the Navy to serve on a ship in the Pacific for several years during WWII, though he was beyond draft age by that time), endured all kinds of hardship, had an office in the family home and saw patients there on nights and weekends, made house calls, gave a lot of free care to those who could not afford it, practiced until his 70s, etc., I find the OP's complaining more than a bit troubling.
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Re: Physicians: Should I leave my job?

Post by toocold »

S4C5 wrote: Tue Sep 22, 2020 9:08 am
dodecahedron wrote: Tue Sep 22, 2020 9:06 am
toocold wrote: Tue Sep 22, 2020 7:49 am Are you sure the hospital bills you out at $12M? Most treatments are a combination of professional fees and facility fees, and just looking at a recent bill, it's almost 1:10. Most health systems actually lose money on the professional side but make it up on the facility side. Before you pursue your own practice, you should understand the economics better.
I agree that you need to understand the economics better.

The hospital might be "billing you out" at $12M but the amount they actually *receive* from third party insurers is typically a small fraction of what they bill. Typical bills have unrealistically high and inflated "sticker prices" that essentially nobody pays. Then you have the uninsured patients with little or no assets. It does not matter what you bill them because you can't get blood from a stone.

With the economy the way it is, tens of millions of people have lost jobs and the health insurance coverage that went along with it. Even many small businesses that are struggling to keep folks on the payroll are talking about ending employee health care benefits. Insurance companies may respond by driving tougher and tougher bargains with providers.

Also, we do not know your medical specialty but keep in mind that medical breakthroughs could make you obsolete. (Think of all the docs in the 1950s who specialized in treating polio and TB.)
I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
Plus healthcare costs are now running 18-19% of GDP, and medical inflation has been running much higher than the normal economy. As a nation, we are paying about $11k per person. Something will eventually change - it's unsustainable.
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S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

dodecahedron wrote: Tue Sep 22, 2020 9:34 am
S4C5 wrote: Tue Sep 22, 2020 9:08 am I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
If you are aware of the payor mix and billing to collection ratio, then I am sure the third-party payors are also very much aware. And they are likely to drive harder bargains in these exceptionally troubled times when they negotiate reimbursement rates. With GDP declining and financial uncertainty looming, the extreme amounts (by international standards) that Americans have paid for health care in recent years may very well be unsustainable.

As the grand-daughter of a physician who did his residency in the late 1920s, then practiced during the Great Depression (and then volunteered for the Navy to serve on a ship in the Pacific for several years during WWII, though he was beyond draft age by that time), endured all kinds of hardship, had an office in the family home and saw patients there on nights and weekends, made house calls, gave a lot of free care to those who could not afford it, practiced until his 70s, etc., I find the OP's complaining more than a bit troubling.
Yes, I'm worried about not being able to negotiate as well with payors and having a harder time making it in solo practice in coming years. I don't have a crystal ball.

With regards to the latter part of your post, my concern is that if I'm bringing in the system and it's not going to me, it's going somewhere else. How much is fair as to what my compensation should be as a percentage of the revenue I generate with my medical license is up for debate. I'm not sure why you are troubled by my concerns that the hospital system is keeping a lot of my revenue. It sounds like you're saying I'm greedy. If I were a solo practitioner, I could choose how to bill and who to treat pro bono. I cannot set my level of service presently, and the hospital employs someone to figure out how to bill as maximally as possible from my notes. Presently, I have a patient who is self-pay and the hospital is refusing to let me treat her unless she can provide the cash up front, which she cannot. Who's the bad guy here?
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Re: Physicians: Should I leave my job?

Post by BruinBones »

I was hospital employed for over 8 years doing general ortho and very little of my fellowship trained subspecialty before I burned out. I suggest trying to stay and finish your contract, but drop scheduling Fridays ( if it’s in your contract your are legally entitled to) and just remain as productive on 4 workdays. Then use your free time to stay in shape (you can still be active when you’re 40) and also to maximize your side business. You might find that you want to continue your side business and drop clinical medicine altogether in 4 and a half years since you are on the path to FI.
Can they terminate you without cause, and do you have a non compete restriction?
eagleeyes
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Re: Physicians: Should I leave my job?

Post by eagleeyes »

dodecahedron wrote: Tue Sep 22, 2020 9:34 am
S4C5 wrote: Tue Sep 22, 2020 9:08 am I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
If you are aware of the payor mix and billing to collection ratio, then I am sure the third-party payors are also very much aware. And they are likely to drive harder bargains in these exceptionally troubled times when they negotiate reimbursement rates. With GDP declining and financial uncertainty looming, the extreme amounts (by international standards) that Americans have paid for health care in recent years may very well be unsustainable.

As the grand-daughter of a physician who did his residency in the late 1920s, then practiced during the Great Depression (and then volunteered for the Navy to serve on a ship in the Pacific for several years during WWII, though he was beyond draft age by that time), endured all kinds of hardship, had an office in the family home and saw patients there on nights and weekends, made house calls, gave a lot of free care to those who could not afford it, practiced until his 70s, etc., I find the OP's complaining more than a bit troubling.

I think comparing a physician from the 1920s to 2020s is more than a bit ridiculous. The practice of medicine, the governing rules and regulations of medicine, medical malpractice, insurance industry, hospital industrial complex, would be unrecognizable to a physician from the 1920s.

More than likely, OP can see more patients in a few days than grandad in a month, just accounting for geographical constraints of how hard it was to get around back in the 1920s.

We don’t begrudge computer IT folks, lawyers, or business folk etc from getting paid what they are worth relative to how much money they are bringing in, why are people finding his behavior troubling?
oldfort
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Re: Physicians: Should I leave my job?

Post by oldfort »

eagleeyes wrote: Tue Sep 22, 2020 10:22 am
dodecahedron wrote: Tue Sep 22, 2020 9:34 am
S4C5 wrote: Tue Sep 22, 2020 9:08 am I'm aware of the payor mix and the billing to collections ratio, and it's quite favorable for the system!
If you are aware of the payor mix and billing to collection ratio, then I am sure the third-party payors are also very much aware. And they are likely to drive harder bargains in these exceptionally troubled times when they negotiate reimbursement rates. With GDP declining and financial uncertainty looming, the extreme amounts (by international standards) that Americans have paid for health care in recent years may very well be unsustainable.

As the grand-daughter of a physician who did his residency in the late 1920s, then practiced during the Great Depression (and then volunteered for the Navy to serve on a ship in the Pacific for several years during WWII, though he was beyond draft age by that time), endured all kinds of hardship, had an office in the family home and saw patients there on nights and weekends, made house calls, gave a lot of free care to those who could not afford it, practiced until his 70s, etc., I find the OP's complaining more than a bit troubling.

I think comparing a physician from the 1920s to 2020s is more than a bit ridiculous. The practice of medicine, the governing rules and regulations of medicine, medical malpractice, insurance industry, hospital industrial complex, would be unrecognizable to a physician from the 1920s.

More than likely, OP can see more patients in a few days than grandad in a month, just accounting for geographical constraints of how hard it was to get around back in the 1920s.

We don’t begrudge computer IT folks, lawyers, or business folk etc from getting paid what they are worth relative to how much money they are bringing in, why are people finding his behavior troubling?
Very few lawyers, business, or IT folk make $650k. Of those who do, almost none are working 40 hour weeks. In the big picture, the OP has a unicorn job: top 1% income, sub-40 hour work weeks, and enough vacation time to travel internationally a lot(pre-COVID).
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S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

eagleeyes wrote: Tue Sep 22, 2020 10:22 am We don’t begrudge computer IT folks, lawyers, or business folk etc from getting paid what they are worth relative to how much money they are bringing in, why are people finding his behavior troubling?
It's funny. In any other profession, the professional sets their fee upfront and it is paid. When a lawyer or an accountant tells you the fee for their service is $300/hour, you know exactly what your bill will be. There is no haggling after the fact, no middleman, no different level of prices for different payors, and no secret chargemaster. In medicine, after medicare, physicians have no idea what they are getting paid and patients have no idea what their bill is going to be. The prior poster's grandparent almost certainly practiced in a very different environment pre-medicare. So yeah, it's kind of comparing apples and oranges.
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Watty
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Re: Physicians: Should I leave my job?

Post by Watty »

Not a doctor so just a few comments;

1) Do all your calculations in after tax dollars. It doesn't really matter if some choice would increase or decrease your income by $100K. What matters is how that would impact your after tax income.

S4C5 wrote: Tue Sep 22, 2020 5:07 am I'm 36 years old ......

I'd like to be out of the game by age 50 and at least partially retired in the Caribbean or Europe or somewhere similar.
2) That is only 14 years from now. I didn't really follow all the details about doing things like starting a private practice but 14 years does not seem like a long enough time to count on doing that and building up your business. It might also take years to sell your practice if that is what you wanted to do. A huge advantage of being an employee is that, within your contract, you can just give your notice and leave the job.

3) Rethink retiring in the Caribbean. It is a great place to visit or maybe even spend a month in each year but I have read several accounts of people trying to live there and it sounds like for many people it gets old after a few years. There is also a LOT of poverty in the Caribbean once you get out of the tourist areas. Hawaii might be an alternative to consider and in fact you might even look to see if you could find a job and move there now. Of course it also sounds like it also has a lot of drawbacks if you actually live there.
Last edited by Watty on Tue Sep 22, 2020 11:00 am, edited 1 time in total.
Big Dog
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Re: Physicians: Should I leave my job?

Post by Big Dog »

1. It's not "your" clinic, it's the hospital's clinic. (They maybe using the clinic's profits to subsidize losses in other departments; its management 101.
2. Irrelevant if you are under a contract. When your contract is up, ask for a raise. Or, ask for a raise now. At worse, they can say No. (Don't resign first and then ask for more money. Just ask for more money now. And if they don't give it up, start looking around.)
3. Is there a medium-sized town within an hour's drive in which you could live and commute?
4. "Everyone"? Highly unlikely. If you have a written contract that clearly states a 4-day workweek, but they need you on Fridays, start taking Monday off (or Wednesday...) Forget the PTO. If they need you five days a week, ask for a raise (see #2), or tell HR that you will happily fulfill your contract of a four-day workweek.


Clearly you are frustrated and unhappy; not everyone was cut out to be a good worker bee. (of course, nearly everyone thinks that they should be boss, or could be a better boss than the current boss...) So it doesn't hurt to start looking for ownership possibilities. (The $125k clawback could be worth it for your happiness.) But note, your Quality of Life will change big time. As a business owner, you won't have the freedom to "travel the world." You won't be working banker's hours. You'll have to pay your own malpractice insurance. For the money you are making now, you will have to work 2x as many hours in nearly every other place. Maybe those new challenges will invigorate you, but I have my doubts.

btw: what were you thinking to build a custom house in a place you do not like?
oldfort
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Re: Physicians: Should I leave my job?

Post by oldfort »

S4C5 wrote: Tue Sep 22, 2020 10:35 am
eagleeyes wrote: Tue Sep 22, 2020 10:22 am We don’t begrudge computer IT folks, lawyers, or business folk etc from getting paid what they are worth relative to how much money they are bringing in, why are people finding his behavior troubling?
It's funny. In any other profession, the professional sets their fee upfront and it is paid. When a lawyer or an accountant tells you the fee for their service is $300/hour, you know exactly what your bill will be. There is no haggling after the fact, no middleman, no different level of prices for different payors, and no secret chargemaster. In medicine, after medicare, physicians have no idea what they are getting paid and patients have no idea what their bill is going to be. The prior poster's grandparent almost certainly practiced in a very different environment pre-medicare. So yeah, it's kind of comparing apples and oranges.
None of this means being a lawyer is a better job. In big law, the 60+ hour work weeks never end and asking for Fridays off would be taken as a joke. In a big firm, you always have a boss, think of the managing partners as like the hospital administration. Until you make equity partner, and 95% of associates never make it, expect to be paid a small fraction of whatever the firm bills clients for your time.
folkher0
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Re: Physicians: Should I leave my job?

Post by folkher0 »

S4C5 wrote: Tue Sep 22, 2020 5:07 am I'm 36 years old and finished residency a little over a year ago and took the highest paying job I could find. I graduated with no debt as I had a side business that earned me around 100k/year throughout medical school and residency. I've done well in terms of making money from work, but not in terms of from investments. I have about $500k in a brokerage account (taxable), $200k in savings, and probably $250k in various retirement plans. I'd like to be out of the game by age 50 and at least partially retired in the Caribbean or Europe or somewhere similar.

For the purposes of anonymity, I won't disclose my specialty here, but I'm in a small subspecialty with a tight job market. Like most subspecialties, the main worries for the future are oversupply driving down revenues and job opportunities and geographic flexibility if I want to make a lateral move.

The job I took was hospital employed in a rural area. I was given a $125k signing bonus (which has been wasting away in a CD at 2.8%), but it's tied to a 5 year forgiveness clause (if I leave before 5 years I have to pay a prorated portion back). My salary is $650k/year with a $70/wRVU conversion factor. In other words, I need around 9300 wRVU per year to make up my salary guarantee and anything beyond that is bonus. I SHOULD be making around 11,000 wRVU per year, which would be around $770k/year income (but I'm not, see below).

Here are the problems with my current position:

1. I am an employee. I heard about the pitfalls of this but had to experience it first-hand to see how badly hospital administrators really treat physicians they employee. I have no control over my clinic. I can't hire and fire insubordinate staff. I can't get the hospital to invest a dime in anything for my patients (even if I can prove it will generate income in the long-term, let alone if it's the right thing for patient care). It's maddening.
2. Income. $650k/year sounds like a lot, but my department bills out probably 1 million a month. I know I am very profitable to the system and make them a lot of money. The wRVU bonus is basically a scam. The hospital is apparently notorious for not paying our this bonus. I tried to audit the records on my own to discover why my wRVU numbers were so low and I discovered that they are not reporting wRVU based on date of service, but to date of billing, which is often months behind. So, for example, if I earned 11,000 wRVU in a calendar year with 2k wRVU in December, but they were a month behind in billing, when the bonus was calculated on January 1, I would only have 9000 wRVU for the year and would not receive a payout. I called them on this scheme and a heated argument ensued. They promised they would tie wRVUs to date of service "for me only," but as this was such an egregious bait-and-switch, I have little faith I will ever receive any wRVU-based production bonus. I have talked to other physicians about how wRVUs are calculated here, and they are appalled. The hospital likes to hire young physicians, and it's obvious why. They want people who are naïve to how the business works.
The benefits are awful. I am maxing out my 403b and 457b (19k/year each), but the company match doesn't start until after 2 years and doesn't fully vest until 5 years later.
3. Location. It's extremely rural. There is nothing here and oddly the cost of living is very high.
4. Lies. The people I work for consistently lie. A great example is that when I signed my contract I was promised a 4 day work week (in writing). When I showed up, they wanted me to work Fridays. As a compromise, I agreed to work Fridays but that I would be allowed to bank 52 Fridays a year as PTO. I now have 82 days a year of PTO total. That's a lot of PTO to try and use (and find locums coverage for), and of course, we aren't compensated for unused PTO. And of course, when I'm gone for weeks at a time, they aren't giving me the wRVUs my clinic is producing. Whereas if I had Fridays off, I wouldn't be doing any work/earning any income on those days anyway since I get it all done in the other 4 days. So basically, I'm losing 52 days a year of wRVU bonus. Those are expensive vacation days. Additionally, being gone that much is bad for continuity of care and I have to spend a lot of time when I get back tidying everything up.

The pros of my current position:
1. Time off/lifestyle. I was enjoying travelling all over the world until COVID hit. Regardless, my job is pretty chill. I show up around 8:30 and can leave by 4 most days. No call and no weekends. No travelling to outreach clinics. However, without being able to travel and having no kids, this is fairly pointless and boring. I'd rather work more and make more money.
2. Income. Even though I feel like I should be making more considering how rural the system is and how much I bill, I still make around the 75th percentile level compared to my peers.

I have realized fairly quickly, the path to success in my field is ownership, which is something very few of us are able to accomplish. Most are employees. However, some are able to buy into private practices and earn incomes around 1-1.5 million. Finding these parternship track positions is difficult, and they typically require 2-3 years of a $300k associate salary.

I have been interviewing and am faced with 4 very different options:
1. Hospital employee in a much better location (a coastal resort area). If I could talk them into letting me invest in the practice as some sort of joint venture, I would be interested. I really want to have some skin in the game and actual potential for higher reward for more work and growing the practice. I'm not sure I want to just keep earning the same salary no matter what I do forever.
2. Private practice in a multispecialty group. All partners regardless of specialty make the same income, which is about what I make now. It's in a city (Minneapolis) instead of a rural area, but the weather is far worse and requires a lot more work, travel, and with less time off. The upside is that I would no longer work directly for the hospital.
3. Starting my own practice. I have been talking to a few other doctors and we see an opportunity in a very rural area near where I am now that is not served. The downsides are much more financial risk and really going off the beaten path, but the upside is that if we had our own practice, we could be collecting the same $1 million/month my current practice is currently turning over to the hospital system.
4. Resign my current position and attempt to negotiate higher pay. At this point, I think it would take a salary guarantee of $800k for me to stay, and I don't see the hospital agreeing to that. And I'm not even sure that's worth all the other B.S.

The two major financial considerations in leaving are the payback of my $125k signing bonus and the fact that I just built a custom $600k house here that is nearing completion and I will have 20% in and may be difficult to sell to re-coup my expenses.

So, should I stick with it here or go with one of the other options above? Word has gotten around that I'm considering leaving and admin has scheduled a meeting with me later this week.
IMO you need to take an honest assessment of what you want MOST. Do you value professional autonomy? Higher salary? Guaranteed income? Big city? Early retirement?

You probably won't be able to max out on all of these. Most of the complaints you have about administration are pretty standard, and will likely be present in any hospital system. Bottom line is you get paid more than most docs 1 year out of fellowship, and work less than most docs 1 year out of fellowship (I don't know what field you're in, of course). Everything else is kind of splitting hairs. You took the biggest paycheck you could find. Of course that means the benefits are gonna be lower.

I may be reading between the lines too much but it seems to me that you really don't like being in a rural environment. That's fine, but there are downsides to living in the big city too. Back in April I dreamed of a W-2 job in the sticks....
sergio
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Re: Physicians: Should I leave my job?

Post by sergio »

With your current savings and income you can be FI by the end of the 5-year contract. Yes, being an physician employee might suck in some ways, but there are upsides as well (don't need to worry about the business/financials/HR/etc. of the practice, you don't need to deal with insurance directly, your personal money is not invested in the practice, you have more geographic mobility etc.) More physicians are moving to becoming employees rather than the other way around.

We have a family member that's a pediatrician, and she just switched to a part-time set up (M-Tues-Weds, 7am-3pm) with limited call, in her early 50s. She plans to basically keep going at this level indefinitely since she loves her job, but wants more time since grandkids are coming into the picture. She's getting paid $110k/year for this...
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Watty
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Re: Physicians: Should I leave my job?

Post by Watty »

S4C5 wrote: Tue Sep 22, 2020 5:07 am Like most subspecialties, the main worries for the future are oversupply driving down revenues .......

So, should I stick with it here or go with one of the other options above? Word has gotten around that I'm considering leaving and admin has scheduled a meeting with me later this week.
When is your contract up for renewal?

It is obvious that you are not happy there so there is a chance that they will not renew your contract and they may have even hired your replacement already. They may be just as frustrated with you as you are with them.

With the pandemic going on someone in a big troubled urban hospital might love to take your position.

I never worked in Medicine but at the company I worked for it was not at all uncommon to hear of some executive suddenly leaving the company about three years after they were hired. It was pretty clear to everyone that that they had a three year contract that was not renewed.
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S4C5
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Re: Physicians: Should I leave my job?

Post by S4C5 »

Thanks for all the replies.

I think I've needed a healthy dose of perspective, especially from physicians who have taken the risk and debt to build their own centers or join a multispecialty private practice. The current situation is that my job is cushy, but I have no control over what goes on in my clinic and the treatments I can offer to my patients (no autonomy), and I have very limited upward mobility of income beyond my fixed salary.

My ideal scenario is if the hospital on the coast will hire me as an employee and let me invest in the center. I.e., have the best of both worlds. Not have as much income potential as if I were the sole owner but also reasonably motivate me and feel like I've got some skin in the game knowing I will be rewarded for trying to grow the practice vs. just collecting a straight salary. Whether they will go for this, I don't know. If they just want me to be an employee, then I might take it anyway as the location would be far better.
Tattarrattat
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Re: Physicians: Should I leave my job?

Post by Tattarrattat »

You seem to want many things at the same time. Can't have it all, probably can't even have half:

High guaranteed pay
Lots of time off
Fun urban location
Competent honest administrators
Congenial honest partners
No business risk
No call, weekends
Don't have to answer to anyone
Astronomical entrepreneurial payoff
Etc

If you priotitize this list, the decision may become clearer. Right now you are earning a lot more than a great majority of MDs with much less work and responsibilities, not a bad gig. If you choose something different, you will almost certainly lose some of what's good right now. No free lunches here.
bhough
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Re: Physicians: Should I leave my job?

Post by bhough »

Let's get specific.

When you talk about "billing", you need to distinguish professional fees from facilty fees. I assume you are a Radiaiton Oncologist if you are working those hours and not taking call. Or perhaps IR. But not Neurosurgery or CT surgery as you would need to be on call. If you are Rad Onc or IR, the facility fee is not something you can get if you "go out on my own". You have to buy a linear acceletor. If you are IR, you have to buy a suite of tools (flouro, accesss to nuc med, etc). You also need to distinguish between total RVUs and work RVUs as they are different. Also need to clarify the personnel costs of the practice. If you are using a dosimetrist, physicist, two techs, etc. those are very high personnel costs. If you are another specialty, the same arguments apply---I doubt they are billing out $1 million/month in wRVUs as you can't do that from 8-4 (you really can't do that 6a-8p either).

Next, the hospitals always win. They'll sue you if you violate your non-compete. They'll complain to the state medical board for abandonment if you don't give them enough notice. They are not your friend and it should be no surprise that they lie to you.

You don't strike me as an employee, but you probably won't be able to start a practice on your own. Interview at 10 private practices around the country and find out: 1) what their non-compete is 2)what their partners make (they probably won't tell you) 3)what your call responsibility is 4)what their ancillaries are (what real estate or machines they own that generate passive income and how much you have to pay to buy in).

Only after you get these details can you weigh your options. You may find the other options are worse and if you want to get out of medicine, buy a $100,00 house (I call bullsh*t on rural setting with high cost of living, sorry) and save your money for 4 years. You will be no more happy retiring on $70,000 than you will on $300,000, but you'll spend decades more tryijng to get there.

Lastly, take all of your vacation and give the hospital 6 months notice of each week off. Then explain, it is their responsibility to find coverage given you have given them 6 months' lead time. If you are rural and tell them a week advance that you need a vacation, that is your mistake, not theirs.

Sorry for the tough love, but you are young and are being abused by a system that has had decades or practice. Time to listen to the music and make some tough decisions.
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