Help me choose between two jobs?

[Barleycorn]

Leaving my current 4 man ortho group as the financial setup was not great. Looking at two jobs in a major metro area.

1) Big box ortho group with multiple locations in the state, there are about 50 to 60 employed docs including orthos, rheum, pain, and ED for the urgent care they have. There are three pain guys, I'd be replacing a fourth guy who is leaving because he lived 2 hours away. They are doing mostly bread and butter spine procedures with minimal opioids. Everything is collections based with them taking 35% (and also a 70-80k "shared rent" on top of that) before the rest is applied to your malpractice and benefits, the rest is then your W2 compensation. Salary is a 250k draw starting day one, they have all broken even in the first year, usually getting to 300k of W2 compensation. Guys who have been there for 6-7 years are seeing 30 patients a day with around 4 weeks of vacation, collecting around 1.5 million and getting a W2 compensation of 600k to 700k.
Commute would be about 50 min, wouldn't have to relocate.
Partnership is for orthos only, pain and rheum have asked in the past, the answer is no.
They have an ASC, but no possibility for buy in, the pain guys mostly just do stuff in office.

2) Joint injection clinic set up by a nurse and his PA wife (yes I know). They have three locations in different states, their model is to set up in states where it is low cost to do business. Commute for me would be at least hour and 20 min, and I'd probably have to move to achieve that. Their model is to market direct to patients over TV, radio, digital for "no surgery, no pills" joint pain treatment. The vast majority of patients are Medicare, and the majority of injections are visco and steroid injections to the knee. They also do genic RFA done by PAs or NPs (yes, I know). They have a family med, moonlighter type guy doing H and Ps, and then a PA or NP will do the injections under fluoro. Collections for each of the locations is about 2 million, net income is for each location is like 400k to 500k. They spend a lot on advertising for each location, like 200k. They would like to add spine and hire a real interventional pain doc, who could also go out and market to other physicians. They are offering 350k either W2 or 1099 plus 30 percent of spine collections (not net collections). They said they are also willing to consider me purchasing a 10-15% of the LLC after a year. They are purchasing a surgery center as well, 10% of that could be purchased as well.

Let me know any advice please!

---

Members don't see this ad.

 

[BobBarker]

No and no.

 

[kstarm]

I got done reading the first one and was feeling no thanks, and then I read the 2nd option....What is option 3 any other private practice options, hospital based options or VA?

50min commute sucks in a major metro area, plus it sound like you are going to have to bust it to make bank without any chance at the real money in partnership. Option 2 has a lot of weird things about it. Maybe you could get in there, carve your niche and turn things around to a practice that works for you but you are always going to working with/against people who think they know what they are doing in this area without actually having fellowship training. Seems like a chance for liability if you are the MD name on this outfit.

Do you have a spouse/partner that is keeping you in the area?

 

[Barleycorn]

I got done reading the first one and was feeling no thanks, and then I read the 2nd option....What is option 3 any other private practice options, hospital based options or VA?

50min commute sucks in a major metro area, plus it sound like you are going to have to bust it to make bank without any chance at the real money in partnership. Option 2 has a lot of weird things about it. Maybe you could get in there, carve your niche and turn things around to a practice that works for you but you are always going to working with/against people who think they know what they are doing in this area without actually having fellowship training. Seems like a chance for liability if you are the MD name on this outfit.

Do you have a spouse/partner that is keeping you in the area?

Pain jobs are kind of tight around here. PP jobs have been mostly shady. My spouse is keeping me in the area, yes. I thought 30 pts a day was fairly standard for a busy place? I guess there's always anesthesia, but I do enjoy pain more.

 

[au bon pain]

If these are really (really) your only 2 options, I would do job #1 part-time 2-3 days/wk to keep your skills up + prn gas$$$. Bide your time there while you look to find something better.

#2 is simply too shady to contemplate (especially with the collections they’re quoting) and there’s no way I’d take my marching orders from noctors

If you have time/energy, just open your own practices across the street from the jokers doing #2. Do a better job and enjoy their lunch.

 

[paindoc007]

Both suck

 

[Agast]

Number 2 just broke my heart. But a word of warning to anyone considering this - Noctors consider you their hired man and will use your name to sign off on all sorts of things they may never tell you about. Because doctors are the ones who have the highest authority to order medications and studies, prescribe DME etc. once they have a copy of your signature it’s over. And you will have zero proof that you weren’t involved.

 

[BobBarker]

So you are ABA boarded anesthesiology and pain?

You do realize that you can make probably $750k per year easy money working at any hospital in middle America?

I just spent the weekend in Wichita, KS and it seemed like a fantastic city. Much more affluent than I expected.

 

[oreosandsake]

If these are really (really) your only 2 options, I would do job #1 part-time 2-3 days/wk to keep your skills up + prn gas$$$. Bide your time there while you look to find something better.

#2 is simply too shady to contemplate (especially with the collections they’re quoting) and there’s no way I’d take my marching orders from noctors

If you have time/energy, just open your own practices across the street from the jokers doing #2. Do a better job and enjoy their lunch.

👍🏼👍🏼👍🏼

 

[Dr. Ice]

Aside from the no chance of buy in/partnership thing, 30 patients a day and 6-700k is hardly something to scoff at. Partnership isn’t so wonderful all the time. People don’t seem to get that sometimes being employed and able to walk making that kind of money/year is not terrible

 

[nvrsumr]

Option 1 all day long. The other is career suicide. Do locums gas and start your own painpractice. If noctors can do it so can you.

 

[RoloTomassi]

They are purchasing a surgery center as well

They are going to crank out knee injections in an ASC? That's got OIG investigation written all over it

I just spent the weekend in Wichita, KS and it seemed like a fantastic city.

Ha! I'm from there

 

[GoBeers]

i don't get why people are discounting #1.

big city area, #1 seems like a standard 9-5 job with great pay. isnt mgma salary for gas pain like $500-600k?
seems like a great employee gig. in office procedures, average volume, good pay.

 

[Barleycorn]

They are going to crank out knee injections in an ASC? That's got OIG investigation written all over it

Ha! I'm from there

The idea is that I would do spine stuff there, but yes I guess I could get pressured into putting my name on or near shady stuff.

For those saying why I don't look for more PP jobs, after six months of looking my other contenders were guys who had investigations or patient fatalities.

The search continues. Thank you all so much for your help, it is really valuable.

 

[callmeanesthesia]

Option 1 doesn’t seem too bad to me, although 50 minute commute would suck. That’s a decent earning potential.

Option 2, I agree with the comments above. That’s people who want to use your license and will fire you if you don’t play along, or if you try to do too much actual doctoring (I bet you’d get a talking to if you canceled an injection because it wasn’t indicated, or because their A1C is 15, or the patient said they didn’t want it and you didn’t talk them into it)…

 

[lobelsteve]

The idea is that I would do spine stuff there, but yes I guess I could get pressured into putting my name on or near shady stuff.

For those saying why I don't look for more PP jobs, after six months of looking my other contenders were guys who had investigations or patient fatalities.

The search continues. Thank you all so much for your help, it is really valuable.

Patient fatalities could be a good practice to join, they are thinning out the herd, eliminating the weak. Natural selection....

 

[Ducttape]

id suggest doing anesthesia for a year, scrimp up money, and wait for something good to come up (it always does), or open up your own practice, probably in the direction opposite to the big city...

if you are in the NE, i keep getting texts about part time anesthesia gigs, and one of them is to do anesthesia at a pain clinic. maybe doing some anesthesia with these pain guys may open up doors?

 

[Barleycorn]

id suggest doing anesthesia for a year, scrimp up money, and wait for something good to come up (it always does), or open up your own practice, probably in the direction opposite to the big city...

if you are in the NE, i keep getting texts about part time anesthesia gigs, and one of them is to do anesthesia at a pain clinic. maybe doing some anesthesia with these pain guys may open up doors?

Thank you but unfortunately not in the NE.

I've thought about opening my own practice, but do people still do it in big, saturated cities or suburbs? I'd have to put a few years or so in preparation to do it the right way. I'm also cash strapped because of my last gig and kind of need money now. One of the main reasons I was considering job 2 was the ability to possibly buy the entire location since they have all the equipment and set up there. They would probably quote me 2M, but I would get a consultant to try to get a real price.

 

[Ducttape]

oh please dont be associated at all with #2.

 

[GoBeers]

Thank you but unfortunately not in the NE.

I've thought about opening my own practice, but do people still do it in big, saturated cities or suburbs? I'd have to put a few years or so in preparation to do it the right way. I'm also cash strapped because of my last gig and kind of need money now. One of the main reasons I was considering job 2 was the ability to possibly buy the entire location since they have all the equipment and set up there. They would probably quote me 2M, but I would get a consultant to try to get a real price.

most people who start their own pain practice in big city do anesthesia or part time established pain practice and rent a clinic space 1 or 2 days a week and potentially do procedures few times a month, including saturday mornings. it seems to take the standard 2 years to be busy.
market heavily to get cash pay or PI volume or try to fight to get onto in-network contracts (usually entails accepting garbage rates) and deal with the horde of good and bad referrals.

 

[clubdeac]

#1 isn’t terrible but if you see that many patients you should be making 800-900 not 600-700

#2 is disgusting and you should report them.

 

[Tramadeezy]

30 patients a day with a 50+ minute commute and 4 weeks of vacation is a recipe for burnout.

 

[gdub25]

No and no.

@BobBarker, curious why no on job #1. 4 weeks vacation, percentage of collections pay structure where it seems like overhead is in the 40-45% range and take home pay is 600-700k for 30 patients per day. That doesn’t sound bad at all to me, especially considering it’s such a large group where it’s harder to stay lean on overhead. Would have built in referral base from partners as well.

Only downside I see is 1: no ASC ownership but as long as their not forcing you to do procedures in the ASC and making you earn based off facility pro fees then it’s not the end of the world; 2: at risk of being the dumping ground for pills from ortho partners after they do surgery.

 

[GoBeers]

#1 isn’t terrible but if you see that many patients you should be making 800-900 not 600-700

#2 is disgusting and you should report them.

#1, if others before him collect 1.5million based off that presume volume, no way they would get 900k.
30 patient workload isn't eye-opening and getting 600k is a great annual income ,well within the range of pain docs across the country, especially as a W2 employee. if you aren't opening your own practice, there isn't much to discuss other then finding a job that is reasonable/enjoyable/has group comradarie and getting paid around the median income (and this #1 option seems like it could be good).

 

[Status Sciaticus]

They are going to crank out knee injections in an ASC? That's got OIG investigation written all over it

Ha! I'm from there

why would OIG audit knee injections in the ASC?
Assuming that you dont have fluoro in the office, where would you do it?

 

[BobBarker]

@gdub25 you would make more money with out dealing with ortho as a hospital employee

 

[au bon pain]

For those saying why I don't look for more PP jobs, after six months of looking my other contenders were guys who had investigations or patient fatalities.

Uhhhh what?

If that’s the case and there’s no good competition nearby, then you have struck an even bigger goldmine than previously described. If you try to do PT work with option 1 do not accept any sort of meaningful non-compete or any over-reaching non-solicitation clause. Plan to open your own practice, stay ethical, do decent work, and you will be well-rewarded.

 

[Barleycorn]

30 patients a day with a 50+ minute commute and 4 weeks of vacation is a recipe for burnout.

How many patients a day are you guys seeing/how much vacation? I'm including injections when I say "patients". I feel like I can see 25 now without too much trouble. A private practicey attending at my fellowship told me 30 pts a day was "industry standard". Option 1 would allow me to take more vacation, but based on threads here I though most people took 4 to 6 weeks.

 

[Ronin1]

I usually have about 35 patient encounters a day. Maybe 20 if a half day. My NP sees some of them if I’m tied up. I get about 5 weeks off plus holidays plus a week of cme. I honestly don’t always use it since I usually only work 3 and 1/2 days a week. If I take a week off I end up working 4 to 4 1/2 days the other weeks it seems due to volume. It’s a productivity model. HOPD

 

[MitchLevi]

Option 2 is a never event.

Option 1 isnt terrible.

 

[Barleycorn]

Option 2 is a never event.

Option 1 isnt terrible.

Apparently I grossly overestimated the value of LLC and surgery center ownership. Glad I asked you guys.

 

[Dr. Ice]

If an attending pain doc can’t see 30 patients a day…that’s just sad. If you really understand what you can offer and what you can’t and what you won’t do, it’s not hard.

If someone thinks that that amount of patients per day will burn someone out, I don’t know what kind of ridiculous Cush lifestyle they are living, but I would say that is the norm

 

[MitchLevi]

Apparently I grossly overestimated the value of LLC and surgery center ownership. Glad I asked you guys.

Maybe, maybe not. ASC could be large sums of money, but they’re not always gold mines. Like Gdub said, if you’re not being forced to do procedures in the ASC this isn’t a terrible job. If your procedures were all ASC, you’d make a lot less money.

 

[MitchLevi]

If an attending pain doc can’t see 30 patients a day…that’s just sad. If you really understand what you can offer and what you can’t and what you won’t do, it’s not hard.

If someone thinks that that amount of patients per day will burn someone out, I don’t know what kind of ridiculous Cush lifestyle they are living, but I would say that is the norm

I perfectly guarantee you 30 per day is not the norm.

 

[HyperSonic]

I usually have about 35 patient encounters a day. Maybe 20 if a half day. My NP sees some of them if I’m tied up. I get about 5 weeks off plus holidays plus a week of cme. I honestly don’t always use it since I usually only work 3 and 1/2 days a week. If I take a week off I end up working 4 to 4 1/2 days the other weeks it seems due to volume. It’s a productivity model. HOPD

How much do you take home before taxes with that set up?

 

[Tramadeezy]

30 clinic patients a day, day in and day out sounds awful.

 

[Barleycorn]

Maybe, maybe not. ASC could be large sums of money, but they’re not always gold mines. Like Gdub said, if you’re not being forced to do procedures in the ASC this isn’t a terrible job. If your procedures were all ASC, you’d make a lot less money.

I perfectly guarantee you 30 per day is not the norm.

What is the norm?

 

[MitchLevi]

What is the norm?

I would guess 25. Volume isn’t volume isn’t volume. I’d argue the quality of the referral is most important. If you’re recruiting procedures off 90% of your pts but you’re only seeing 20 per day, that’s good volume IMO. I think a solid goal is at least 200 procedures per month, or avg 50 per week. If those are all done in a procedure room (not ASC) you’re doing very well.

 

[gdub25]

@gdub25 you would make more money with out dealing with ortho as a hospital employee

Good point

 

[Taus]

Reasonable # patients per day…..I think it depends upon % new consult vs follow-ups and somewhat of practice setting, I.e. primarily procedural, med management, versus “comprehensive pain“. Straightforward problems vs more complex chronic pain issues.

 

[Ronin1]

Exactly. Of my 35 patients:
10 procedures
10 med management
10 procedure fu
5 : new patients or miscellaneous

95% spine practice. It’s honestly very easy once you have experience and good staff

 

[nvrsumr]

I had 164 patient visits last week. work 35 hours/week spread over 5 days. I’m also running a business.

Edit- busier than usual week

 

[Taus]

I had 164 patient visits last week. work 35 hours/week spread over 5 days. I’m also running a business.

3 days week of 21-23 clinic/day for me. About 50:50 new vs follow-up. 8a-5:30p including all dictations, messages, procedure prep, etc. No scribe, no midlevel.

2 days/week of office fluoro 25-30 procedure/day. Mixture of my own patients, partners who don’t do cervicals/rfa and direct esi from spine surgeons and their PAs.

2 OR days /month

I feel max’d out at this volume. Any more and either the quality of my care and/or sanity would suffer. Doesn’t mean others can’t do a great job a lot faster than me…. just in my personal circumstances I cannot.

 

[au bon pain]

Reasonable # patients per day…..I think it depends upon % new consult vs follow-ups and somewhat of practice setting, I.e. primarily procedural, med management, versus “comprehensive pain“. Straightforward problems vs more complex chronic pain issues.

Another thing that's of course implicit in what you're saying, but maybe not totally clear to fellows who may be reading this: quality of support from the practice. Examples that really do matter are:

How good is the front desk staff staff? Are they pleasant but able to be firm when needed? Can they effectively screen many of the "I need to ask the doctor a quick question" patients?

Do you have a dedicated RN or MA? More than 1? Do they reliably complete tasks? Can they get a focused history from the patient and give you a one-liner as you head into the patient's room (and, even better, are they able to document it in the visit note)? Are they able to anticipate your / patient needs and head off potential issues before they present?

Do you have Dragon? Scribes? Both? Are there reliable/usable computers available for you everywhere you need them?

How many rooms do you have? Are patients always appropriately gowned / painful area exposed by the time you walk in the room? Is patient imaging already open on PACS?

If you have none of this stuff, seeing 2 or 3 fu pts/hr can be tough. If you have all of them, seeing 3 or 4 new pts/ hour may be easy.

 

[Ducttape]

If an attending pain doc can’t see 30 patients a day…that’s just sad. If you really understand what you can offer and what you can’t and what you won’t do, it’s not hard.

If someone thinks that that amount of patients per day will burn someone out, I don’t know what kind of ridiculous Cush lifestyle they are living, but I would say that is the norm

I would guess 25. Volume isn’t volume isn’t volume. I’d argue the quality of the referral is most important. If you’re recruiting procedures off 90% of your pts but you’re only seeing 20 per day, that’s good volume IMO. I think a solid goal is at least 200 procedures per month, or avg 50 per week. If those are all done in a procedure room (not ASC) you’re doing very well.

if one is doing purely spine and being funneled interventional referrals, 30 a day may be [possible on a daily basis. 25 is more reasonable.

but if one is doing chronic pain, including chronic spine pain and chronic pain from other locations (abdomen, pelvic pain patients take significantly longer to not only prep but to treat), combined with the need to use language interpreters, 30 patients a day is a pipe dream and will burn every one of us out.

 

[jwalker12]

I usually have about 35 patient encounters a day. Maybe 20 if a half day. My NP sees some of them if I’m tied up. I get about 5 weeks off plus holidays plus a week of cme. I honestly don’t always use it since I usually only work 3 and 1/2 days a week. If I take a week off I end up working 4 to 4 1/2 days the other weeks it seems due to volume. It’s a productivity model. HOPD

Are you in a major metro area? Every time I read about your gig it just gets better and better

 

[MitchLevi]

HOPD has the highest floor in terms of pay, but you’re also a hospital employee and they can screw you without recourse. Staffing issues, block time, etc…

 

[Doctodd]

find something on gaswork