Physician Specialists Looking for career advice

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IndexBeliever
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Physician Specialists Looking for career advice

Postby IndexBeliever » Fri Apr 22, 2016 2:45 pm

Dear Bogleheads,

I am a first year fellow in a subspecialty. Looking for career advice. Any advice or experience regarding the following would be helpful.

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

2. Would a BogleHead be completely opposed to taking on debt to join a group?

3. Any drawbacks to being a hospital employed physician?

Thanks!

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gasdoc
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Re: Physician Specialists Looking for career advice

Postby gasdoc » Fri Apr 22, 2016 5:02 pm

I would be very careful about taking on significant debt to buy into a group. The group could be bought out by an outside entity, leaving you with a large debt and an organization where you may not get your investment back out of the group. Or worse, you may decide that you don't like or don't fit into the group for whatever reason, and want to leave.

gasdoc

Loon11
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Re: Physician Specialists Looking for career advice

Postby Loon11 » Fri Apr 22, 2016 9:19 pm

get a position in a VA Medical Center. the specialists don't do primary care. You will have a pension and benefits and can contribute to the TSP, best 401K in the country.

kmurp
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Re: Physician Specialists Looking for career advice

Postby kmurp » Fri Apr 22, 2016 9:47 pm

gasdoc wrote:I would be very careful about taking on significant debt to buy into a group. The group could be bought out by an outside entity, leaving you with a large debt and an organization where you may not get your investment back out of the group. Or worse, you may decide that you don't like or don't fit into the group for whatever reason, and want to leave.

gasdoc

Would you not get back your money as a shareholder when the buyout occurs?

am
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Re: Physician Specialists Looking for career advice

Postby am » Fri Apr 22, 2016 10:07 pm

Avoid hospital employment. You will feel like a postal worker. No control over anything around you. Dead end. On the other hand, if you join a private group, your time may be limited given alarming trends...

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White Coat Investor
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Re: Physician Specialists Looking for career advice

Postby White Coat Investor » Fri Apr 22, 2016 10:08 pm

IndexBeliever wrote:Dear Bogleheads,

I am a first year fellow in a subspecialty. Looking for career advice. Any advice or experience regarding the following would be helpful.

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

2. Would a BogleHead be completely opposed to taking on debt to join a group?

3. Any drawbacks to being a hospital employed physician?

Thanks!


1. I prefer to own my job. You may feel differently. The smaller the group, and the more democratic the group, the closer you will be to owning your job.

2. No.

3. Yes. You don't own your job, with all the pluses and minuses that entails.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

desiderium
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Re: Physician Specialists Looking for career advice

Postby desiderium » Fri Apr 22, 2016 10:26 pm

It depends on your specialty. If you generate large downstream revenue for others, then employment with hospital or multi specialty group can make you valuable and well compensated. If you can generate ancillary income, then keeping this within a practice can be a good arrangement. The problem with practice right now is rapid change. Reimbursements are going down in many cases, and contracting is getting way more complicated. Ultimately, organizations will be driven to taking on risk, and independent practices are going to be very busy keeping up with this market.

Starting out you don't want to have to worry about this. A well run, medium size specialty or multispecialty practice can provide the cover for the business end while you get started. Hospital employment can be good or bad, depending on the organization.

Buy-in's are mostly a bad deal, and are fairly uncommon anymore. I would be very wary about this. Similarly, non-compete clauses can be asymmetric and often times ethically questionable. Physician contracting is usually complicated and you are presumably at a disadvantage in terms of knowledge. I would get a good contract advisor and/or attorney to assist with this. You can negotiate.

staythecourse
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Re: Physician Specialists Looking for career advice

Postby staythecourse » Fri Apr 22, 2016 10:47 pm

IndexBeliever wrote:Dear Bogleheads,

I am a first year fellow in a subspecialty. Looking for career advice. Any advice or experience regarding the following would be helpful.

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

2. Would a BogleHead be completely opposed to taking on debt to join a group?

3. Any drawbacks to being a hospital employed physician?

Thanks!


1. The only true answer is there is no answer. It all depends. If there was one ideal employment practice then you would already know it because everyone would be clamoring for those positions. Here are some points of each. Multispecialty: It is nice because you have internal referral sources, but often animosity develops because you are producing more revenue yet have to share it with the primary docs and/ or arguments happen over appropriate %'s of overhead that needs to be covered by docs from different specialties in the practice. Single specialty: Nice to be surrounded by others in the same field trying to be successful as a group. Issues seem to arise due to senority where the senior guys think it is okay to take adv. of the junior guys in relation to pay, work hours, or both. Hospital employed: You just come to work as any other rank and file employee, BUT don't get any adv. of being a rank and file emlployee (OT, etc...). You will always be treated like a slave which I guess you really are as you just do the dirty work of the employer who are business guys in suits who are surprisingly BAD at running a business. That can be frustrating as obvious things that can improve care and/ or generate revenue falls on deaf ears as admin. are usually not the brightest minds in any room.

In the end you need to choose what has the LEAST amount of negatives and which allow you to have the highest chance of accomplishing whatever you really want in life. The hardest part of talking to med. students, residents, and fellows is having them understand life does not begin and end at work. One has to find what will bring them happiness. Some it is money, some it is being independent, and some is just clocking in and out so they can focus on family, friends, and/ or hobbies. What will it be for you?

2. This question is too vague to answer. If you are taking on debt to buy equity into a practice I would be a little hesitant. Many practices are merging or selling so I would be wary of spending money on hopefully buying into a practice and then in the end they end up selling with you being left out of the deal. Besides makes no sense ANY intelligent group would even offer you a buy in as they don't know if you are even a right long term fit for the group. Why would you marry someone without even dating?

3. Plenty just like any employment.

Best advice I can give is assume you will get screwed and it will be a learning experience. Just make sure 1. Who covers tail if you quit vs. they fire you, 2. How much notice needs to be given if you or they want to separate, 3. If litigation occurs who covers legal fees if one wins vs. loses, and 4. what is your state law in regards to validity of restrictive covenants.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

staythecourse
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Re: Physician Specialists Looking for career advice

Postby staythecourse » Fri Apr 22, 2016 10:54 pm

desiderium wrote:It depends on your specialty. If you generate large downstream revenue for others, then employment with hospital or multi specialty group can make you valuable and well compensated.


Not so. As you can imagine a group or hospital could make EVEN more if you do the same work with less pay. The delta is extra revenue for the group/ hospital. In these two employments you do NOT own the patients. Like any employer they will offer you X salary for a Y service. If you think you deserve more they will let you walk.

2 reasons: 1. They assume you are successful because of them and thus any doctor in same field will reproduce the same results (but with lower pay).
2. If you walk who cares as you don't get to take the patients with you which is why you have no leverage in negotiations.

The last is what happens ALL the time when independent docs sell their practices to hospitals. They work for them a couple of years and when they start getting screwed on salary and/ or time they have no recourse as they have no patients to take to go on their own.

The BIGGEST strength a physician has is their patient load. That is what hospitals are buying NOT your expertise. As they know once they have that you become expendable if need be.

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

ace1400
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Re: Physician Specialists Looking for career advice

Postby ace1400 » Fri Apr 22, 2016 10:59 pm

1. This depends on your field. If you are comfortable disclosing which area of medicine you are going into, you may get more helpful advice. In general, subspecialists get most of their patients via referrals from other physicians, so a larger multispecialty group has the advantage of a built-in referral network. On the other hand, you may be the only doc doing what you do in the entire practice, and it may be more difficult to get the resources you need for whatever it is you do in terms of equipment and staffing, depending how different those needs are from the other members of the group.

A specialty specific group can be awesome as far as multiple colleagues doing what you do, a complete understanding of the field and a facility already equipped for the field. The staff understands what you do and the coding/billing for your field is well understood by the practice. You can share call in your subspecialty. The downside is that, in some markets dominated by large multispecialty health systems, this may not be a sustainable model depending on the area of medicine and the degree of interaction with other medical specialties. There are some very strong independent groups in some areas, but in other areas doctors not part of the dominant health system get by on the margins. This is highly location and community attitude dependent. In some areas, not being associated with the dominant player means you get the referrals from everybody else who is also not affiliated with them, which can still be a significant segment of the population. I would be more concerned in a market with 2-3 dominant systems that have the vast majority of the doctors and population.

Avoid a hospital employed position if at all possible. Your commitment to your patients means nothing to hospital administrators, no matter what lip service they pay to the contrary. They care about your profit margin (yes, this is true even at nonprofit hospitals) and not much else. A friend was sacked recently by the hospital that employed him. They closed the whole department of which he was a part. They were "going in a different direction" after a new administrator took over. The previous administrator had aggressive built up the department. They let all the doctors go and closed the department with two weeks notice. In a surgical specialty. Without making any provisions whatsoever as to how his post operative patients would be cared for. They thought his four months of severance was all that was needed.

The hospital also doesn't care in the slightest how inefficiently you are forced to work. Even efficiency improvements that make them more money are unlikely to be implemented if they take any resources whatsoever because they have to deal with organization as a whole. I.e. if having a scribe will allow you to see 5 more patients per day and get home 4 hours earlier, they will still say no because they don't want everybody in the system demanding the same thing. Another friend recently left hospital employment after he proposed a more efficient clinic arrangement with scribes and increased patient volume etc. He was having to stay until 10 PM charting every night, and it was impacted his marriage. The hospital's respond? They suggested marriage counseling.

2. Taking on debt to buy a job is reasonable, if the income from the job you buy is significantly better than other similar jobs. You can often increase your income by 50-100% by owning your job compared to a salary position. The return on this purchase/investment can be extremely attractive, but it does have some risk. Transactions I am familiar with have purchase prices usually in the range of 75-125% of the partner's expected net income, but this can vary widely. Many groups will finance your purchase to some degree, and doing the purchase with preferential distributions can be tax efficient. The devil is in the details, as always, and you would like to understand how the practice has done this in the past - they probably won't change for you.

3. See above.

This was longer than I planned. If you have a geographic area targeted, understanding the economic situation with regard to your specialty in that area will be very helpful.

Tal-
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Re: Physician Specialists Looking for career advice

Postby Tal- » Fri Apr 22, 2016 11:00 pm

I'm not a doctor, but I work around strategic planning for a mid-sized healthcare system. So, take this for what it's worth...

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

My read of the tea leaves is that healthcare will go through major consolidation in the near future, and most smaller specialty groups will face pressure to closely align to larger groups - be that large multi specialty clinics (with a few hundred providers) or hospitals. I think that this will blur the lines of employment if you choose to go with a smaller practice.

2. Would a BogleHead be completely opposed to taking on debt to join a group?

I can't speak to this.

3. Any drawbacks to being a hospital employed physician?

Within my healthcare system, employed providers (especially specialists) are given a fair bit of autonomy - both as individual providers and as a group/clinic. There's always some tension there with the providers wanting more independence and the system trying to standardize things, but my read is that specialists will remain a hot commodity, and will continue to have a lot of autonomy. (note that if you're working as any form of a hospitalists or within primary care, the rules change a bit).

In the future, all restaurants will be Taco Bell...
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ace1400
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Re: Physician Specialists Looking for career advice

Postby ace1400 » Fri Apr 22, 2016 11:12 pm

One additional point: Hospitals often pursue revenue shifting between doctors and hospital services from insurance companies. It goes like this: when the insurance contract comes up for renegotiation, the hospital offers the insurer a X% cut in reimbursement for services provided by hospital employed physicians with a commensurate Y% increase in hospital charges. If it is revenue neutral to the insurance company, they will usual agree. Then the hospital goes to the employed physicians and tells them they are collecting less revenue and hence their pay is being cut. Or this cut happens automatically if the physician is paid via some productivity bonus based on collections.

What this means is an employment offer from a hospital system with a productivity based compensation arrangement may look better on paper and be much worse in practice than an unaffiliated physicians group.

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Tozmo
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Re: Physician Specialists Looking for career advice

Postby Tozmo » Sat Apr 23, 2016 2:01 am

I work for a hospital group. We do make less than private groups typically do. However, we don't have to deal with:

The outside threat of a contract management group negotiating with the hospital/health system to replace us or buy us out
The business men (mentioned above as surprisingly being bad at running a business which usually is true) squeezing us for less pay. In my health system, they want to retain physicians, so they keep pay for each service line comparable to state/area same-specialty reimbursement. If they threatened to cut pay, they would lose people. Having the deep coffers of a system to back up salaries is helpful.
Partner disagreements regarding schedule and call because of seniority or other weird factors
Quarterly meetings trying to figure out how to increase revenue, cut costs, or deal with patients who won't pay
Hospitals trying to renegotiate privilege contract in their favor
Scribe funding
Staff funding

Granted, in my group we don't get the oversight that I have heard happens at HCA hospitals, team health, etc that is all metric numbers of dubious importance and not helpful or productive to physician life.
I am ok with my hospital-employed position. I know its limitations. Many of my friends either work for a contract management group or a private group that got bought out and grumble about the changes. It is nice to be a small fish in a big ocean as a hospital employee because of its dilution effect sometimes. Also, unlike previous jobs with a private group, with all physicians in my hospital working for the same employer, there is more of a "same team" feeling.

neuro84
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Re: Physician Specialists Looking for career advice

Postby neuro84 » Sat Apr 23, 2016 7:07 am

As a resident, I'd like to thank all of the Boglehead physicians who took the time to post in this thread.

I'm taught by doctors who chose to do academic medicine, and they've only ever known the employee model (and a very specific version of it - employed by a large academic healthcare system). As such, the career advice I get from my attendings is often a bit monochromatic in tone. It's very refreshing to hear accounts from physicians with experience in other employment categories.

I would like to one day join a partner-owned practice, because autonomy is second to none in my career goals. It seems the vast majority of young physicians go immediately for employed models (either community hospital-owned PP or large academic system). I hope this trend doesn't mean the end of private practice during my career.

Thanks again for shoring up the deficiencies in my education.

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gasdoc
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Re: Physician Specialists Looking for career advice

Postby gasdoc » Sat Apr 23, 2016 7:37 am

staythecourse wrote:
desiderium wrote:It depends on your specialty. If you generate large downstream revenue for others, then employment with hospital or multi specialty group can make you valuable and well compensated.


Not so. As you can imagine a group or hospital could make EVEN more if you do the same work with less pay. The delta is extra revenue for the group/ hospital. In these two employments you do NOT own the patients. Like any employer they will offer you X salary for a Y service. If you think you deserve more they will let you walk.

2 reasons: 1. They assume you are successful because of them and thus any doctor in same field will reproduce the same results (but with lower pay).
2. If you walk who cares as you don't get to take the patients with you which is why you have no leverage in negotiations.

The last is what happens ALL the time when independent docs sell their practices to hospitals. They work for them a couple of years and when they start getting screwed on salary and/ or time they have no recourse as they have no patients to take to go on their own.

The BIGGEST strength a physician has is their patient load. That is what hospitals are buying NOT your expertise. As they know once they have that you become expendable if need be.

Good luck.


+1. It is all about who owns the patients.

gasdoc

am
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Re: Physician Specialists Looking for career advice

Postby am » Sat Apr 23, 2016 8:39 am

gasdoc wrote:
staythecourse wrote:
desiderium wrote:It depends on your specialty. If you generate large downstream revenue for others, then employment with hospital or multi specialty group can make you valuable and well compensated.


Not so. As you can imagine a group or hospital could make EVEN more if you do the same work with less pay. The delta is extra revenue for the group/ hospital. In these two employments you do NOT own the patients. Like any employer they will offer you X salary for a Y service. If you think you deserve more they will let you walk.

2 reasons: 1. They assume you are successful because of them and thus any doctor in same field will reproduce the same results (but with lower pay).
2. If you walk who cares as you don't get to take the patients with you which is why you have no leverage in negotiations.

The last is what happens ALL the time when independent docs sell their practices to hospitals. They work for them a couple of years and when they start getting screwed on salary and/ or time they have no recourse as they have no patients to take to go on their own.

The BIGGEST strength a physician has is their patient load. That is what hospitals are buying NOT your expertise. As they know once they have that you become expendable if need be.

Good luck.


+1. It is all about who owns the patients.

gasdoc




Amen. Many physicians, especially us hospital based docs become impotent expendable workers when we are employed. We have no patients and are film readers, anesthesia administrators, slide readers or ER clinicians to them. Who cares about working conditions, happiness, any control over practice or surroundings etc. Pay those suckers as little as possible without them leaving. I often think I should have been the 9-5 administrator chatting on the phone and taking long lunch breaks for 6 figures.

staythecourse
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Re: Physician Specialists Looking for career advice

Postby staythecourse » Sat Apr 23, 2016 8:59 am

am wrote:Amen. Many physicians, especially us hospital based docs become impotent expendable workers when we are employed. We have no patients and are film readers, anesthesia administrators, slide readers or ER clinicians to them. Who cares about working conditions, happiness, any control over practice or surroundings etc. Pay those suckers as little as possible without them leaving. I often think I should have been the 9-5 administrator chatting on the phone and taking long lunch breaks for 6 figures.


I'm not even looking down on hospital employment. The issues comes in when folks sign up or sell their practice to X without really researching BEFORE HAND what are the negatives that come with X. ALL employment situations have negatives. The key is understanding and accepting them before you sign up. The biggest thing I have noticed from young to even more experience docs is NOT understanding some simple accounting. Doctors perceive themselves to be on the ASSETS side of a ledger, but in fact they are on the LIABILITIES side. The biggest cost for most businesses are labor costs and the highest of that are obviously physician salaries. Now management feels they are adding value (not sure why they assume that but that is a different argument) vs. their employees who just perform job X for Y pay and add not extra value. Another aspect that is hard for ANY company is how to motivate any worker to do what is best for the company's bottom line when they are not taking home a share of the excess profits. Why should you work hard if you don't get to take home any more pay?

As for the hospital admin. vs. employees (including docs) unfortunately this is no different then ANY job in a capitalistic country. The job of the employer or management is to get as MUCH profit as possible. Their interests are NOT aligned with the physician which is to give good quality care and either make a lot of money, have autonomy, or have time off or some combo. of the 3. Socialist look at this work situation as further alienation of the worker from the final product. That is the biggest criticism of ANY capitalistic venture.

My wife is in corporate medicine and I will give you the same advice I gave her and her partners and that is in corporate medicine the goal is NOT to hop to make more money then your salary, but to do as little as possible and not get fired. If you have that attitude you are better off then hoping, "If I am stellar and bring in profits I'll get reimbursed better".

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

am
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Re: Physician Specialists Looking for career advice

Postby am » Sat Apr 23, 2016 9:25 am

staythecourse wrote:
am wrote:Amen. Many physicians, especially us hospital based docs become impotent expendable workers when we are employed. We have no patients and are film readers, anesthesia administrators, slide readers or ER clinicians to them. Who cares about working conditions, happiness, any control over practice or surroundings etc. Pay those suckers as little as possible without them leaving. I often think I should have been the 9-5 administrator chatting on the phone and taking long lunch breaks for 6 figures.


I'm not even looking down on hospital employment. The issues comes in when folks sign up or sell their practice to X without really researching BEFORE HAND what are the negatives that come with X. ALL employment situations have negatives. The key is understanding and accepting them before you sign up. The biggest thing I have noticed from young to even more experience docs is NOT understanding some simple accounting. Doctors perceive themselves to be on the ASSETS side of a ledger, but in fact they are on the LIABILITIES side. The biggest cost for most businesses are labor costs and the highest of that are obviously physician salaries. Now management feels they are adding value (not sure why they assume that but that is a different argument) vs. their employees who just perform job X for Y pay and add not extra value. Another aspect that is hard for ANY company is how to motivate any worker to do what is best for the company's bottom line when they are not taking home a share of the excess profits. Why should you work hard if you don't get to take home any more pay?

As for the hospital admin. vs. employees (including docs) unfortunately this is no different then ANY job in a capitalistic country. The job of the employer or management is to get as MUCH profit as possible. Their interests are NOT aligned with the physician which is to give good quality care and either make a lot of money, have autonomy, or have time off or some combo. of the 3. Socialist look at this work situation as further alienation of the worker from the final product. That is the biggest criticism of ANY capitalistic venture.

My wife is in corporate medicine and I will give you the same advice I gave her and her partners and that is in corporate medicine the goal is NOT to hop to make more money then your salary, but to do as little as possible and not get fired. If you have that attitude you are better off then hoping, "If I am stellar and bring in profits I'll get reimbursed better".

Good luck.


Thanks. I like the "do as little as possible and not get fired". Tough to get into that mindset after gunning for several decades through school and early career. But the bean counters are constantly monitoring productivity and behavior and am sure have no problem replacing an underperforming physician. I have had to be somewhat of a politician and keep my mouth shut since I need the job to support family. Never thought that I would end up like the average joe employed fill in the blank as a doctor.

ks289
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Re: Physician Specialists Looking for career advice

Postby ks289 » Sat Apr 23, 2016 9:40 am

staythecourse wrote:
am wrote:Amen. Many physicians, especially us hospital based docs become impotent expendable workers when we are employed. We have no patients and are film readers, anesthesia administrators, slide readers or ER clinicians to them. Who cares about working conditions, happiness, any control over practice or surroundings etc. Pay those suckers as little as possible without them leaving. I often think I should have been the 9-5 administrator chatting on the phone and taking long lunch breaks for 6 figures.


I'm not even looking down on hospital employment. The issues comes in when folks sign up or sell their practice to X without really researching BEFORE HAND what are the negatives that come with X. ALL employment situations have negatives. The key is understanding and accepting them before you sign up. The biggest thing I have noticed from young to even more experience docs is NOT understanding some simple accounting. Doctors perceive themselves to be on the ASSETS side of a ledger, but in fact they are on the LIABILITIES side. The biggest cost for most businesses are labor costs and the highest of that are obviously physician salaries. Now management feels they are adding value (not sure why they assume that but that is a different argument) vs. their employees who just perform job X for Y pay and add not extra value. Another aspect that is hard for ANY company is how to motivate any worker to do what is best for the company's bottom line when they are not taking home a share of the excess profits. Why should you work hard if you don't get to take home any more pay?

As for the hospital admin. vs. employees (including docs) unfortunately this is no different then ANY job in a capitalistic country. The job of the employer or management is to get as MUCH profit as possible. Their interests are NOT aligned with the physician which is to give good quality care and either make a lot of money, have autonomy, or have time off or some combo. of the 3. Socialist look at this work situation as further alienation of the worker from the final product. That is the biggest criticism of ANY capitalistic venture.

My wife is in corporate medicine and I will give you the same advice I gave her and her partners and that is in corporate medicine the goal is NOT to hop to make more money then your salary, but to do as little as possible and not get fired. If you have that attitude you are better off then hoping, "If I am stellar and bring in profits I'll get reimbursed better".

Good luck.


I agree with a lot of what you are saying, and you clearly have well thought out positions.

I would disagree about how much power and leverage physicians can have in both hospital employed and private practice settings. Physicians are not purely labor (or a liability) because unlike the valet or gift shop attendant, their services (E/M, procedures) and actions (tests ordered, facility fees) are the product and drive revenues. In some cases, physicians who have ancillaries, surgical centers, or go to multiple hospitals can have a huge impact on the profits for a health system. They also have the potential to have an impact from an administrative and leadership perspective. Of course, this may all change as reimbursement models change!
No matter what the circumstance, if your value and production could be easily replaced (by a new grad, mid level, competing group), then certainly you have little leverage. However, many parts of the country are underserved, so even if you are easily replaceable, you can always find a setting where you are in demand.

staythecourse
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Re: Physician Specialists Looking for career advice

Postby staythecourse » Sat Apr 23, 2016 10:05 am

ks289 wrote:I agree with a lot of what you are saying, and you clearly have well thought out positions.

I would disagree about how much power and leverage physicians can have in both hospital employed and private practice settings. Physicians are not purely labor (or a liability) because unlike the valet or gift shop attendant, their services (E/M, procedures) and actions (tests ordered, facility fees) are the product and drive revenues. In some cases, physicians who have ancillaries, surgical centers, or go to multiple hospitals can have a huge impact on the profits for a health system. They also have the potential to have an impact from an administrative and leadership perspective. Of course, this may all change as reimbursement models change!
No matter what the circumstance, if your value and production could be easily replaced (by a new grad, mid level, competing group), then certainly you have little leverage. However, many parts of the country are underserved, so even if you are easily replaceable, you can always find a setting where you are in demand.


I agree with what you wrote. What I wrote is not what I believe, but what admin. believes. Unfortunately MANY employers (not just hospitals or in medicine) feel any employee is replaceable. It seems many folks just think replace x with y and save z dollars and there you go you have a larger profit margin. That, of course, is NOT true. The big assumption they make is assuming person A who has shown they are profitable for you can be replaced with person B who will be just as profitable but cost you less. Not correct, but I think it helps to think that way for them to make the accounting work.

In the end, all that happens are folks work less as they are not motivated and profits fall. So admin. cuts salaries or increases work hours which either 1. Makes employee upset where they give substandard care to their work (which is hard for us as we care about patient care) or 2. Good physicians leave and find a different job and they are replaced with another physician and the cycle repeats.

The BIG problem in medicine is non compete clauses. This is what prevents a level playing field. Otherwise, Doctor A who is not happy and can not negotiate to improve their situation with their bosses could just leave and go down the street and start their own practice or join a rival group. That is where the leverage is gone. If there is nothing for the employer to lose why negotiate at all?

How in the world of a free market and the capitalistic drive America was built on can we restrict someone from working in an area just because they worked in the same area with someone else?? Makes no sense. Why state medical boards do not pursue changing legislation on restrictive covenants is beyond me. It would only IMPROVE competition and access to the public. Makes no sense!!

What the future of hospital based physicians SHOULD be is to line up with other rank and file employees of a hospital (nurses for example) and unionize. Think about the power we would have. Ask hospital administrator A we want better hours or more support help. He says no. So the union goes okay we pull ALL the nurses and doctors starting on Monday. What do you think the results would be. Medicine is a PERFECT place for a strong union as the it is NOT easy to just replace medical professionals as the number of years working to attain their credentials are not easy to replace. Where is the SEIU on this one??

Good luck.
"The stock market [fluctuation], therefore, is noise. A giant distraction from the business of investing.” | -Jack Bogle

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LowER
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Re: Physician Specialists Looking for career advice

Postby LowER » Sat Apr 23, 2016 10:33 am

There are lots of physicians who profit immensely by eating their young. As stated above, expect to get screwed, and also expect that you will likely not be in that same position in 3 years so don't buy the castle, the sports car, and club membership until you've been around a few years. I've seen too many docs make this stupid maneuver.

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Re: Physician Specialists Looking for career advice

Postby tludwig23 » Sat Apr 23, 2016 10:51 am

You used the plural, "Specialists". Do you have multiple fellowships in different specialties or is there more than one of you?

In my field (anesthesiology), the best method of financial success is being willing to live in some undesirable part of the country. But, those places are undesirable for a reason, so I choose to live in the Pacific Northwest and make less money, as part of a single specialty practice of 40 physicians.
That's what I do: I drink, and I know things. --Tyrion Lannister

SleepKing
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Re: Physician Specialists Looking for career advice

Postby SleepKing » Sat Apr 23, 2016 3:39 pm

Great thread and valueable advice.

Personally, i have seen and expect the smaller, physician groups and practices to be gobbled up to the point of extinction in the next 10-15 years. Employment will either be corporate management company, health system or hospital, or academic center.

To your questions,
1. Any of the options are fine knowing that a small feoup may not be solvent long or the hospital gives your contact to a corporate group...

2. No debt. Usually the salry is reduced x years for buy in tc

3.drawbacks to every employment model. Pick your posion regarding drawbacks.

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Re: Physician Specialists Looking for career advice

Postby goodenyou » Sun Apr 24, 2016 4:21 am

There is a lot of good advice here from experienced physicians. I will give you my take:

I have been in practice as a surgical subspecialist for 20 years. I went to an extremely underserved (but rapidly growing) area when I came out of residency. It was an excellent opportunity to make a lot of money at the time. After 3 years, I became the managing partner of my single specialty group and grew the practice from 2 offices, 5 doctors and 30 employees to 9 doctors, PAs, NPs, 5 offices and 100 employees. We had a full time attorney and CPA and administrator in-house at one point in time, and we were involved heavily in property development. We owned surgery centers, portions of hospitals (now the largest physician owned hospital in the country), imaging centers and billing centers. A lot has changed over the years. We have divested much of our investments, and the hospitals are now getting physician groups to close their private practices and are employing them. Much of the investment opportunity in medicine has dried up with ACA and other regulation. There is little appetite for risk in the current climate. The hospitals are trying to vertically integrate by creating Health Care Systems partly to overcome the challenge of call coverage, "in-network" and "out of network" problems and creation of ACOs. Our group has been approached to be "bought out". However, there is no buyout of good will. There are laws in medicine that prohibit "good will" buy-outs. It is prohibited under the anti-kickback statues. The hospitals can only employ you at the "going rate" (MGMA compensation averages). So, as a shareholder of a group, you would not get any multiple of income stream as in traditional business purchases. If you own property, and the buyer is willing to purchase (at fair market values), this can be a lucrative option to cash out for partners who have owned the property for years or the property has appreciated in value. So, consider this when thinking about a "buy-in". I would not "buy-in" to a practice at this time except in very rare circumstances. In the current medical economic climate and where it appears to be heading, you may never get your money back. You may end up buying out senior partners and left "holding the bag". I won't even go into the pitfalls of buy-sell agreements. I could have an honorary degree in law for all the aggravation I have gone through with crazy partners. I have "seen it all".

If you are paid on some type of RVU compensation model as an employee, remember the efficiency of the system that you may have no control over may dictate your compensation. For example, poor staffing, hospital compliance regulations and lousy EMR (they are ALL crappy) will reduced your productivity/RVUs and ability to bill. Some of us went into this profession for autonomy, and the employment model is the worst option for professional satisfaction.

With the current debt loads of graduating physicians and the changing (reduction) in reimbursement. private practices are very challenged to meet the needed salary guarantees of graduating residents. 90% of my emails for job listings are employed (hospital-based) positions. Private practice cannot compete with these offers. Many practices cannot recruit for succession planning for these reasons. Hospitals derive millions from the downstream revenue (facility fees, labs, imaging etc.) from doctors, and they can lose money on the professional services that constitute salary and still be net positive. Hospitals can charge more for equal services as the OP office setting is often billed as an extension of the hospital. The system is currently set up to drive groups out of private practice and out of a fee-for-service model.

Keep your eyes open. Best of luck.
"Ignorance more frequently begets confidence than does knowledge" | "The best years you have left are the ones you have right now"

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Re: Physician Specialists Looking for career advice

Postby IndexBeliever » Sun Apr 24, 2016 3:04 pm

Loon11 wrote:get a position in a VA Medical Center. the specialists don't do primary care. You will have a pension and benefits and can contribute to the TSP, best 401K in the country.


Do you work for the VAMC? Any VA employees out there can comment? My limited observation has been significantly less compensation, but most work 8-5 (40 hrs a week) with limited call and excellent quality of life.

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Re: Physician Specialists Looking for career advice

Postby IndexBeliever » Sun Apr 24, 2016 3:09 pm

staythecourse wrote:
IndexBeliever wrote:Dear Bogleheads,

I am a first year fellow in a subspecialty. Looking for career advice. Any advice or experience regarding the following would be helpful.

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

2. Would a BogleHead be completely opposed to taking on debt to join a group?

3. Any drawbacks to being a hospital employed physician?

Thanks!


1. The only true answer is there is no answer. It all depends. If there was one ideal employment practice then you would already know it because everyone would be clamoring for those positions. Here are some points of each. Multispecialty: It is nice because you have internal referral sources, but often animosity develops because you are producing more revenue yet have to share it with the primary docs and/ or arguments happen over appropriate %'s of overhead that needs to be covered by docs from different specialties in the practice. Single specialty: Nice to be surrounded by others in the same field trying to be successful as a group. Issues seem to arise due to senority where the senior guys think it is okay to take adv. of the junior guys in relation to pay, work hours, or both. Hospital employed: You just come to work as any other rank and file employee, BUT don't get any adv. of being a rank and file emlployee (OT, etc...). You will always be treated like a slave which I guess you really are as you just do the dirty work of the employer who are business guys in suits who are surprisingly BAD at running a business. That can be frustrating as obvious things that can improve care and/ or generate revenue falls on deaf ears as admin. are usually not the brightest minds in any room.

In the end you need to choose what has the LEAST amount of negatives and which allow you to have the highest chance of accomplishing whatever you really want in life. The hardest part of talking to med. students, residents, and fellows is having them understand life does not begin and end at work. One has to find what will bring them happiness. Some it is money, some it is being independent, and some is just clocking in and out so they can focus on family, friends, and/ or hobbies. What will it be for you?

2. This question is too vague to answer. If you are taking on debt to buy equity into a practice I would be a little hesitant. Many practices are merging or selling so I would be wary of spending money on hopefully buying into a practice and then in the end they end up selling with you being left out of the deal. Besides makes no sense ANY intelligent group would even offer you a buy in as they don't know if you are even a right long term fit for the group. Why would you marry someone without even dating?

3. Plenty just like any employment.

Best advice I can give is assume you will get screwed and it will be a learning experience. Just make sure 1. Who covers tail if you quit vs. they fire you, 2. How much notice needs to be given if you or they want to separate, 3. If litigation occurs who covers legal fees if one wins vs. loses, and 4. what is your state law in regards to validity of restrictive covenants.

Good luck.


Thanks for the advice. "assume you will get screwed and it will be a learning experience." Probably the best advice. Really appreciate your thoughts. It's overwhelming when you have worked so long to become a physician and towards the end get overwhelmed with details that will dramatically impact your life and are outside of medicine. Really appreciate your insight. :sharebeer

IndexBeliever
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Re: Physician Specialists Looking for career advice

Postby IndexBeliever » Sun Apr 24, 2016 3:18 pm

tludwig23 wrote:You used the plural, "Specialists". Do you have multiple fellowships in different specialties or is there more than one of you?

In my field (anesthesiology), the best method of financial success is being willing to live in some undesirable part of the country. But, those places are undesirable for a reason, so I choose to live in the Pacific Northwest and make less money, as part of a single specialty practice of 40 physicians.


Grammar error from lack of sleep! Just one of me. Thanks for the insight. I've noticed that trend as well, you get paid a lot more to be the small town specialist, but with much higher call volume!

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Re: Physician Specialists Looking for career advice

Postby IndexBeliever » Sun Apr 24, 2016 3:22 pm

goodenyou wrote:There is a lot of good advice here from experienced physicians. I will give you my take:

I have been in practice as a surgical subspecialist for 20 years. I went to an extremely underserved (but rapidly growing) area when I came out of residency. It was an excellent opportunity to make a lot of money at the time. After 3 years, I became the managing partner of my single specialty group and grew the practice from 2 offices, 5 doctors and 30 employees to 9 doctors, PAs, NPs, 5 offices and 100 employees. We had a full time attorney and CPA and administrator in-house at one point in time, and we were involved heavily in property development. We owned surgery centers, portions of hospitals (now the largest physician owned hospital in the country), imaging centers and billing centers. A lot has changed over the years. We have divested much of our investments, and the hospitals are now getting physician groups to close their private practices and are employing them. Much of the investment opportunity in medicine has dried up with ACA and other regulation. There is little appetite for risk in the current climate. The hospitals are trying to vertically integrate by creating Health Care Systems partly to overcome the challenge of call coverage, "in-network" and "out of network" problems and creation of ACOs. Our group has been approached to be "bought out". However, there is no buyout of good will. There are laws in medicine that prohibit "good will" buy-outs. It is prohibited under the anti-kickback statues. The hospitals can only employ you at the "going rate" (MGMA compensation averages). So, as a shareholder of a group, you would not get any multiple of income stream as in traditional business purchases. If you own property, and the buyer is willing to purchase (at fair market values), this can be a lucrative option to cash out for partners who have owned the property for years or the property has appreciated in value. So, consider this when thinking about a "buy-in". I would not "buy-in" to a practice at this time except in very rare circumstances. In the current medical economic climate and where it appears to be heading, you may never get your money back. You may end up buying out senior partners and left "holding the bag". I won't even go into the pitfalls of buy-sell agreements. I could have an honorary degree in law for all the aggravation I have gone through with crazy partners. I have "seen it all".

If you are paid on some type of RVU compensation model as an employee, remember the efficiency of the system that you may have no control over may dictate your compensation. For example, poor staffing, hospital compliance regulations and lousy EMR (they are ALL crappy) will reduced your productivity/RVUs and ability to bill. Some of us went into this profession for autonomy, and the employment model is the worst option for professional satisfaction.

With the current debt loads of graduating physicians and the changing (reduction) in reimbursement. private practices are very challenged to meet the needed salary guarantees of graduating residents. 90% of my emails for job listings are employed (hospital-based) positions. Private practice cannot compete with these offers. Many practices cannot recruit for succession planning for these reasons. Hospitals derive millions from the downstream revenue (facility fees, labs, imaging etc.) from doctors, and they can lose money on the professional services that constitute salary and still be net positive. Hospitals can charge more for equal services as the OP office setting is often billed as an extension of the hospital. The system is currently set up to drive groups out of private practice and out of a fee-for-service model.

Keep your eyes open. Best of luck.


Thanks for your time and expertise. It's overwhelming!

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Re: Physician Specialists Looking for career advice

Postby IndexBeliever » Sun Apr 24, 2016 3:23 pm

White Coat Investor wrote:
IndexBeliever wrote:Dear Bogleheads,

I am a first year fellow in a subspecialty. Looking for career advice. Any advice or experience regarding the following would be helpful.

1. Joining a multispecialty clinic vs specialty specific group vs hospital employed position?

2. Would a BogleHead be completely opposed to taking on debt to join a group?

3. Any drawbacks to being a hospital employed physician?

Thanks!


1. I prefer to own my job. You may feel differently. The smaller the group, and the more democratic the group, the closer you will be to owning your job.

2. No.

3. Yes. You don't own your job, with all the pluses and minuses that entails.


I can't thank WCI for his expertise and blog. I started reading it ~2.5 years ago and it has been YUUUUUUGGEEE. Thanks for all you do. In hindsight, ER looks like an excellent career choice!

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Re: Physician Specialists Looking for career advice

Postby cutterinnj » Sun Apr 24, 2016 3:39 pm

I think this really depends on the specialty.

For instance, cardiologists are all pretty much owned by hospitals now. Tons of cardiology private practices have gone out of business/sold out to local hospitals in the past decade; it's just not possible for cardiologists to practice on their own.

Other specialties (particularly surgical sub-specialists as well as gastroenterologists) can still make it in private practice. (Although I strongly suggest against trying to go into solo practice for just about any specialty outside of pure aesthetics.)
As mentioned above, just be careful who you go into business with. A lot of older doctors believe they are owed a lot for the privilege of you joining them. Younger docs tend to be more realistic and family oriented, and won't try to "pull the wool over your eyes" as far as buy-ins, buy-outs, "good will", etc...

I think think the fairest way to do these deals is to have an accountant determine the accounting value of the practice, and a partner's buy in (and buy out) equal the appropriate fraction of that. Anything higher just doesn't make sense.

For example, as a urologist, being in a single-specialty group allows me access to ancillary businesses in surgery centers, radiation centers, real estate ventures, stone machines, etc... If I was owned by a hospital, the hospital would get 100% of this revenue.
This may change over the next few years, but it currently still makes sense to be in group private practice.

desiderium
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Re: Physician Specialists Looking for career advice

Postby desiderium » Sun Apr 24, 2016 3:52 pm

goodenyou wrote:There is a lot of good advice here from experienced physicians. I will give you my take:

I have been in practice as a surgical subspecialist for 20 years. I went to an extremely underserved (but rapidly growing) area when I came out of residency. It was an excellent opportunity to make a lot of money at the time. After 3 years, I became the managing partner of my single specialty group and grew the practice from 2 offices, 5 doctors and 30 employees to 9 doctors, PAs, NPs, 5 offices and 100 employees. We had a full time attorney and CPA and administrator in-house at one point in time, and we were involved heavily in property development. We owned surgery centers, portions of hospitals (now the largest physician owned hospital in the country), imaging centers and billing centers. A lot has changed over the years. We have divested much of our investments, and the hospitals are now getting physician groups to close their private practices and are employing them. Much of the investment opportunity in medicine has dried up with ACA and other regulation. There is little appetite for risk in the current climate. The hospitals are trying to vertically integrate by creating Health Care Systems partly to overcome the challenge of call coverage, "in-network" and "out of network" problems and creation of ACOs. Our group has been approached to be "bought out". However, there is no buyout of good will. There are laws in medicine that prohibit "good will" buy-outs. It is prohibited under the anti-kickback statues. The hospitals can only employ you at the "going rate" (MGMA compensation averages). So, as a shareholder of a group, you would not get any multiple of income stream as in traditional business purchases. If you own property, and the buyer is willing to purchase (at fair market values), this can be a lucrative option to cash out for partners who have owned the property for years or the property has appreciated in value. So, consider this when thinking about a "buy-in". I would not "buy-in" to a practice at this time except in very rare circumstances. In the current medical economic climate and where it appears to be heading, you may never get your money back. You may end up buying out senior partners and left "holding the bag". I won't even go into the pitfalls of buy-sell agreements. I could have an honorary degree in law for all the aggravation I have gone through with crazy partners. I have "seen it all".

If you are paid on some type of RVU compensation model as an employee, remember the efficiency of the system that you may have no control over may dictate your compensation. For example, poor staffing, hospital compliance regulations and lousy EMR (they are ALL crappy) will reduced your productivity/RVUs and ability to bill. Some of us went into this profession for autonomy, and the employment model is the worst option for professional satisfaction.

With the current debt loads of graduating physicians and the changing (reduction) in reimbursement. private practices are very challenged to meet the needed salary guarantees of graduating residents. 90% of my emails for job listings are employed (hospital-based) positions. Private practice cannot compete with these offers. Many practices cannot recruit for succession planning for these reasons. Hospitals derive millions from the downstream revenue (facility fees, labs, imaging etc.) from doctors, and they can lose money on the professional services that constitute salary and still be net positive. Hospitals can charge more for equal services as the OP office setting is often billed as an extension of the hospital. The system is currently set up to drive groups out of private practice and out of a fee-for-service model.

Keep your eyes open. Best of luck.


This is a great summary of the current reality.

I am on the other side of this transition from a private specialty practice to an employed physician. Legally, hospitals must compensate you based on "fair market value", which limits the upside salary to MGMA or something like it, and prohibits sharing of downstream revenue. Doctors drive the majority of health system revenues, so any discussion with hospital administrators has to start with honest accounting. Cost center accounting tends to emphasize how much your practice will "lose", but the whole equation needs to be considered.

Ideally, there is an alignment of interests here. The long term economics favor hospital owned practices that enhance physician productivity, happiness and low turnover--fair compensation, healthy workloads and staffing that minimizes work that doesn't require an advanced degree. This promotes quality and patient satisfaction, which grow the practice. All in all, this is not so different with what you and others have achieved in private practice. I have seen it work to a certain degree and IMO there is cause for hope in some of these employment relationships.

Unfortunately, the downside of the employed relationship is usually in execution. Most physicians are very good at what they do and many are great. Good administrators are much harder to come by. They also take time consuming education and their turnover is high. In our organization we try constantly to contrast the execution of our goals--practice growth, satisfaction, quality outcomes etc. with administrative track record--how they are doing with marketing, IT infrastructure, keeping up with equipment needs, EMR, revenue cycle, and on an on. Administrators looking at the budget see salary--physicians and their support staff as the number one targets in a B-school 101 analysis. Survival in this environment requires a constant effort to keep the focus on their shortcomings in other areas, rather than enter into a discussion about how cutting physician pay, office staffing, etc will help the bottom line.

In many markets, the majority of physicians are now employed. It is easy to see examples where physicians are treated like cogs, over scheduled with unrealistic production goals and limited support. It shows when care becomes rushed, focused on the primary complaint, things are missed, patients are unhappy. There are good counter-examples as well, and these can be realized only by having a seat at the decision-making table.

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Re: Physician Specialists Looking for career advice

Postby s2kmw » Mon Apr 25, 2016 10:40 am

cutterinnj wrote:I think this really depends on the specialty.

Other specialties (particularly surgical sub-specialists as well as gastroenterologists) can still make it in private practice. (Although I strongly suggest against trying to go into solo practice for just about any specialty outside of pure aesthetics.)



Could you expand on this? I understand the issue of declining reimbursements and hospitals beginning to own the referral base, but do you think a solo practice (sugical subspecialty) with a focus on controlling costs is truly not feasible going forward? Is it because of the uncertainty of how the payment model is going to change? They are trying ACO and value-based programs, but these focus mainly on primary care. Not sure how much progress has been made in that area for sub-specialties

Thanks!

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Re: Physician Specialists Looking for career advice

Postby desiderium » Tue Apr 26, 2016 8:52 am

s2kmw wrote:
cutterinnj wrote:I think this really depends on the specialty.

Other specialties (particularly surgical sub-specialists as well as gastroenterologists) can still make it in private practice. (Although I strongly suggest against trying to go into solo practice for just about any specialty outside of pure aesthetics.)



Could you expand on this? I understand the issue of declining reimbursements and hospitals beginning to own the referral base, but do you think a solo practice (sugical subspecialty) with a focus on controlling costs is truly not feasible going forward? Is it because of the uncertainty of how the payment model is going to change? They are trying ACO and value-based programs, but these focus mainly on primary care. Not sure how much progress has been made in that area for sub-specialties

Thanks!


Try bundled payments. Medicare is rolling this out for orthopedics, hip replacement, and it will spread. The hospital and Doctor get one payment for the whole shebang. How does this get split up and who decides? What happens if there are complications or a prolonged length of stay? Medicare is getting out of this mess and letting Doctor and hospital work this out. Good luck negotiating as a solo practioner.

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Re: Physician Specialists Looking for career advice

Postby Tozmo » Tue Apr 26, 2016 9:53 pm

IndexBeliever wrote:
Loon11 wrote:get a position in a VA Medical Center. the specialists don't do primary care. You will have a pension and benefits and can contribute to the TSP, best 401K in the country.


Do you work for the VAMC? Any VA employees out there can comment? My limited observation has been significantly less compensation, but most work 8-5 (40 hrs a week) with limited call and excellent quality of life.


A friend left lucrative private group EM (8 months before TeamHealth bought them) for VA. Her stress level is significantly less. Money is less too, but she picks and chooses her hours, is much happier, and gets the TSP

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Re: Physician Specialists Looking for career advice

Postby mac808 » Tue Apr 26, 2016 10:57 pm

desiderium wrote:
s2kmw wrote:
cutterinnj wrote:I think this really depends on the specialty.

Other specialties (particularly surgical sub-specialists as well as gastroenterologists) can still make it in private practice. (Although I strongly suggest against trying to go into solo practice for just about any specialty outside of pure aesthetics.)



Could you expand on this? I understand the issue of declining reimbursements and hospitals beginning to own the referral base, but do you think a solo practice (sugical subspecialty) with a focus on controlling costs is truly not feasible going forward? Is it because of the uncertainty of how the payment model is going to change? They are trying ACO and value-based programs, but these focus mainly on primary care. Not sure how much progress has been made in that area for sub-specialties

Thanks!


Try bundled payments. Medicare is rolling this out for orthopedics, hip replacement, and it will spread. The hospital and Doctor get one payment for the whole shebang. How does this get split up and who decides? What happens if there are complications or a prolonged length of stay? Medicare is getting out of this mess and letting Doctor and hospital work this out. Good luck negotiating as a solo practioner.


Wouldn't the surgeon have almost all of the negotiating leverage in this situation assuming they could choose from among at least a few different hospitals to operate in?

desiderium
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Re: Physician Specialists Looking for career advice

Postby desiderium » Wed Apr 27, 2016 7:05 am

mac808 wrote:
desiderium wrote:
s2kmw wrote:
cutterinnj wrote:I think this really depends on the specialty.

Other specialties (particularly surgical sub-specialists as well as gastroenterologists) can still make it in private practice. (Although I strongly suggest against trying to go into solo practice for just about any specialty outside of pure aesthetics.)



Could you expand on this? I understand the issue of declining reimbursements and hospitals beginning to own the referral base, but do you think a solo practice (sugical subspecialty) with a focus on controlling costs is truly not feasible going forward? Is it because of the uncertainty of how the payment model is going to change? They are trying ACO and value-based programs, but these focus mainly on primary care. Not sure how much progress has been made in that area for sub-specialties

Thanks!


Try bundled payments. Medicare is rolling this out for orthopedics, hip replacement, and it will spread. The hospital and Doctor get one payment for the whole shebang. How does this get split up and who decides? What happens if there are complications or a prolonged length of stay? Medicare is getting out of this mess and letting Doctor and hospital work this out. Good luck negotiating as a solo practioner.


Wouldn't the surgeon have almost all of the negotiating leverage in this situation assuming they could choose from among at least a few different hospitals to operate in?


Maybe. Presumably it would depend on how many surgeons were in the area, what they were willing to do and what the other hospitals were offering. On the other hand, a group of surgeons might have better leverage.

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Re: Physician Specialists Looking for career advice

Postby cheapindexer » Wed Apr 27, 2016 12:14 pm

plus 1 to what lowER posted earlier.

NEVER take on debt to "buy in" to a group. If the hospital up the road opens a new center to compete with you, you're done!

completely agree don't buy a house (rent), don't buy the sports car, etc until you're comfortable you will be there long term.

I would say life is better as an employed physician. STRONGLY.
Try to make the "no compete" as limited as possible , or eliminate it. If your job has a 90 day "without cause" term for dismissal, NEVER buy a house!

The hardest thing for me career wise, as a 45 year old physician specialist, has been the OTHER PHYSICIANS, BOTH IN MY PREVIOUS GROUPS AND COMPETITORS THEREOF. It's like the Jerry McGuire movie when Jerry gets fired "now I want ALL of my clients, and yours too" (docs just substitute the word "client" with "patient")

reddityeah
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Re: Physician Specialists Looking for career advice

Postby reddityeah » Thu Apr 28, 2016 1:45 pm

anyone with insight into the current practice environment for dermatology?

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Re: Physician Specialists Looking for career advice

Postby White Coat Investor » Thu Apr 28, 2016 5:45 pm

cheapindexer wrote:plus 1 to what lowER posted earlier.

NEVER take on debt to "buy in" to a group. If the hospital up the road opens a new center to compete with you, you're done!

completely agree don't buy a house (rent), don't buy the sports car, etc until you're comfortable you will be there long term.

I would say life is better as an employed physician. STRONGLY.
Try to make the "no compete" as limited as possible , or eliminate it. If your job has a 90 day "without cause" term for dismissal, NEVER buy a house!


I'd be pretty hesitant to say never. What if the debt were $100K and your income were twice as high in the group as out of it? At a certain point, it makes sense.

I've been an employed doc and owned my job. I suspect I'd leave medicine before working as an employee again. Control is worth a lot when it comes to preventing burnout.

I'm not sure I'd NEVER buy a house even with a 90 day without cause clause. But I certainly wouldn't buy a house until I was reasonably certain this was going to work out well in the long term.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

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Re: Physician Specialists Looking for career advice

Postby Matigas » Thu Apr 28, 2016 8:03 pm

Join the Air Force. You can count on a sign on bonus, and loan repayments.

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Re: Physician Specialists Looking for career advice

Postby letsgobobby » Thu Apr 28, 2016 11:57 pm

- medicine is changing rapidly. Taking on huge debt would be very risky.

My piece of advice may sound too "psychiatric" but take it for what it's worth.

Pay attention to the job duties; pay attention to the compensation and benefits; pay attention to the town, community, restaurants, and schools, the patient population, the hospital and clinic facilities.

But more than anything, pay attention to the people. The people you're going to work with every day for, hopefully, many years. Are they happy? Are they excited? Have they been there a long time or has there been endless turnover? Do they seem close? Do they genuinely enjoy each other's company? Do they seem honest? Are they honorable? Do they have families, and do they talk about their families - or only their work? Are they cheerful - but not overly so? Are they backbiting the organization? each other? their nurses? the parking? anything? Are they engaged enough with the organization to provide honest yet constructive criticism, or are they just angry? burned out? embittered? vengeful?

Medicine is undergoing hard change everywhere. Everyone is stressed out; everyone's professional livelihood is threatened. But a well-run organization (or at the very least, department) has found a way to turn these challenges into opportunities, and has found a way to do so without completely frying its docs. Even the most lucrative and otherwise attractive job will be a miserable slog if you dread the people you work with, or worse, can't trust them.

I got flat out lucky coming out of residency. I discovered after the fact how important people were. And I got lucky that the people I work with are genuinely honorable people who - while far from perfect - try to do the right thing almost all the time. Everything else that I've dealt with in the last decade plus has been made tolerable by that fact.

(one more thing; I looked at their cars. My future colleagues drove Toyotas, pick up trucks, and old Volvos. I knew I'd found my home.)

oragne lovre
Posts: 463
Joined: Tue Nov 25, 2008 3:34 pm

Re: Physician Specialists Looking for career advice

Postby oragne lovre » Fri Apr 29, 2016 2:01 am

Since your first job, just like a date, may not result in a stable marriage, you should not take on other financial risks such as purchase of a big house or a fancy car. When I agreed to take my first job, which is fortunately still ongoing, a senior partner told me to enjoy life by getting a mansion-like house and a luxurious car. I, like you, also perused other Bogleheads' advice and decided to go cheap with a comfortable house and my reliable clunker. Several years later, I asked the same guy why he had given such advice from the beginning, he laughed and said that he had wanted me to be in so big a debt that it would be harder for me to leave the group. Looking back, I believe that "go cheap" decision was a wise one, thanks to Bogleheads.
You may want to consider it too.
Good luck!
The finest, albeit the most difficult, of all human achievements is being reasonable.

am
Posts: 2249
Joined: Sun Sep 30, 2007 9:55 am

Re: Physician Specialists Looking for career advice

Postby am » Fri Apr 29, 2016 9:45 am

No question that comfortable house and car are preferred to McMansion and luxury car. I have colleagues who are struggling on specialist MD salaries and are stuck in jobs because of poor housing choices. With the huge changes in medicine, it is comforting to know that I can surivive on much less than I make now. I don't have to move to look for another lucrative position and take my kids out of school. This is priceless and removes a stress from my already stressful life. I personally think that many (most?) doctors are woefully prepared to handful finances at attending salaries and make life changing mistakes that they will never recover from. And I agree with letsgobobby, people you work with are critical to career fulfillment. A bad or unfair boss/chairmen for those of us employed will also kill a job.


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