Buy-In: A Scam or Typical Hurdle in PP?

[pjl]

Our stock provides ownership of 2 ASCs and a hospital. The base level of stock gives me ~0.15% ownership. I invested more and am currently ~1% owner. I have a lot of eggs in that basket, but it is a good basket currently. I did it to prepare for the day when anesthesia and other services fight over the money that is paid lump sum to hospital. I anticipate the hospital will keep more than they will give us, and I wanted to still get some.
Every quarter the extra money the hospital makes over expenses (and a certain amount of cash on hand holdback) gets distributed out to all partners. This set up is rare. So I get ~1% of the hospital profits per year. At the end, I can sell my stock for whatever it is worth at that time.
Every partnership offer and setup is going to be different, some would say I was screwed hard my first year, and they are probably right. However, for me it was a calculated risk that has allowed my situation to be far ahead of where I would have been had I taken that employed or academic job elsewhere.

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[GravelRider]

I know you are upset with the practice that you were or possibly still are in, but I've rotated through (as a resident) private practice groups where the old guys work hard, are good people, deliver a good Anesthetic, and are great mentors to the young guys in the practice. Residents I know have gone on and taken jobs there as a result and have been very happy and feel fairly compensated for their work. I don't think all pp groups are bad situations like yours. Ive followed your posts and have learned a good amount from them (and I'm glad you call out the shady places and speak up), but I don't think all of the older anesthesiologists are washed up greedy businessmen. I sincerely hope you have or do find a way out into another practice or field all together. Being miserable with your job is no way to go through life.

So if a group is fair, stable, and has great leadership, what should the buy in look like?

I like being bitter. It allows me to maintain a critical eye on the scam artists out there. Even if I was in the perfect job situation, I would still call out the bull$hit when I see it. Otherwise, I'm pretty happy with my life, so you don't have to worry there.

As the saying goes: "Fool me once, shame on you; fool me twice, shame on me."

 

[Pharmado]

Question, I've been looking for a job as a 2017 grad across the country where I have no contacts. I'm struggling to find a good PP group and will likely end up taking a hospital employed gig. What is the downside for a new graduate taking a hospital gig? Obviously the worst jobs seem attached to AMC's, which I've tried to avoid like the plague. It seems like a reasonable hospital employed position at say a little over 400k would provide me experience + time + resources to find a fair PP group. I would obviously love to magically happen into the right PP group (or a high paying rural gig even), but that hasn't really happened at this point. Why would new grads like myself chance an unknown PP group with a buy-in when there are hospital employed positions available that they can get into at a higher starting rate without the risk?

 

[Robotic Wis-Hipple]

Question, I've been looking for a job as a 2017 grad across the country where I have no contacts. I'm struggling to find a good PP group and will likely end up taking a hospital employed gig. What is the downside for a new graduate taking a hospital gig? Obviously the worst jobs seem attached to AMC's, which I've tried to avoid like the plague. It seems like a reasonable hospital employed position at say a little over 400k would provide me experience + time + resources to find a fair PP group. I would obviously love to magically happen into the right PP group (or a high paying rural gig even), but that hasn't really happened at this point. Why would new grads like myself chance an unknown PP group with a buy-in when there are hospital employed positions available that they can get into at a higher starting rate without the risk?

This is the rub right? It's a gamble. And this is what IMO many of the PP groups aren't fully understanding other than their assumption that the "millennials are lazy". In this day and age it's quite a gamble to take 250-350k (possibly even as 1099) with 2-3yrs partnership track when you could just take a $400k guaranteed job with good benefits. Now sure, you may eventually get 450k plus bonus, maybe even totaling 600k as a partner 3 years later, but there are a lot of stars that must align for that to happen.

The group has to be non-predatory, has to be healthy (good stable contracts and relationships with hospitals), have partners that want to maintain the group and grow (vs sell out because they are near the end of their careers or because the AMCs are coming at them continuously and they'd rather sell than get pushed out at the hospital contract level), they have to like you enough to make you partner, etc.

This is why as the new grad or potential new hire you need to ask the questions that seem pushy or as if we are overstepping. What does becoming partner mean? Does it just mean they no longer skim off the top or do I get voting rights, profit sharing, and full equal partnership? Are there super-partners? If so, that scares me as a sell off could happen at any time, even more so than it can anyways. Can I see the billing/accounts receivables for the last few recent partners and compare to what new hires are started at so I can truly see what my sweat equity buy in is?

And finally, the old adage that PP makes double or more what academics make does not appear to be even close to true from what I'm seeing. Now of course I haven't seen what full partners are clearing but it is striking to me that there are academic places offering 150k more to start than AMCs and 50-75k more to start than PP groups not even counting the benefits packages the academic departments offer.

I want to do PP, but the climate makes it a huge gamble which I'm not afraid to do.....for the right group.

 

[Arch Guillotti]

And finally, the old adage that PP makes double or more what academics make does not appear to be even close to true from what I'm seeing.

Believe it.

 

[criticalelement]

I know you are upset with the practice that you were or possibly still are in, but I've rotated through (as a resident) private practice groups where the old guys work hard, are good people, deliver a good Anesthetic, and are great mentors to the young guys in the practice. Residents I know have gone on and taken jobs there as a result and have been very happy and feel fairly compensated for their work. I don't think all pp groups are bad situations like yours. Ive followed your posts and have learned a good amount from them (and I'm glad you call out the shady places and speak up), but I don't think all of the older anesthesiologists are washed up greedy businessmen. I sincerely hope you have or do find a way out into another practice or field all together. Being miserable with your job is no way to go through life.

So if a group is fair, stable, and has great leadership, what should the buy in look like?

You are entitled to your own opinion but not your own facts.. The facts dont bear out what you are saying..

The predatorial anesthesia private groups is the RULE rather than the exception.

Exclusive contracts have ruined the specialty.

 

[aneftp]

Believe it.

Some academic packages benefits packages are worth close to $100k these days especially when u factor in reduced (or waived ) in state college tuition for family members (aka kids). Retirement matching 20-25k yearly.

So my cousin makes in the low 300s working essentially 7-5pm at academic place plus calls (I was making in low 300s as well but working more). Regardless salaries similar. Plus benefits package easily pushing total compensation package (occurrence malpractice, health, liberal sick leave) pass $400k a year and upwards to $450k if kids in school for discount or free.

Not many private practice guys making $800k plus even in the heydays. Certainly not in today's environment. My buddy hit $800k a couple of years in fee for service with great payer mix and than economy crashed. Than income tanked to low 400s by 2011 (working SAME hours 665 hours waiting for case)

My sister true private group. Guy who works like a dog (excess of 70 hours a lot) makes in the 700s.

But true private practice making 2x a much as academics is few and far in between these days.

 

[IlDestriero]

It really depends on the group. There are academic jobs paying 250 and others offering >450 with a nice benefit package. You can certainly make more than that in a good PP job. However you have to factor in how much you're working for that income. I'm certain I have a good job, and am well compensated for what I do, but I know many guys in PP making over 600 and taking more vacation. The difference is I'm solo or 2:1 and they're always 3-4:1 and take far more call. Break it down into hours worked and how much you're working while there to really compare apples to apples. Then there's the tax advantages of group ownership, profit sharing, etc. that always will go to the PP guys.


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Il Destriero

 

[Arch Guillotti]

But true private practice making 2x a much as academics is few and far in between these days.

Disagree.

 

[aneftp]

Disagree.

I can tell u with almost 100% certainly a new grad rolling in to a major city top 10 pop city like DC, Dallas, Miami, NYC, Atlanta, LA ain't going to find a partnership track position with the promises to make $700-800k.

Sure. Can u still find those jobs elsewhere (biggest bang for the buck with mid size cities). Yes the money is there for a 2-3 year partnership for that type of money.

 

[Mman]

The scam part wasn't the profit sharing but the fact partner wasn't a true partnership based on the fact that if the group sold then I wouldn't get a partner share, ever. I would get some chunk thrown in but if partners sold for a few million each the figures I was told would be a tenth of that. Pahhhlease. That's shady.

then you weren't offered partnership, you were offered employee profit sharing

 

[PainDrain]

then you weren't offered partnership, you were offered employee profit sharing

No ****. It was a shady situation. Disingenuous offer thinking I was naive enough to bite.

 

[Hoya11]

This is the rub right? It's a gamble. And this is what IMO many of the PP groups aren't fully understanding other than their assumption that the "millennials are lazy". In this day and age it's quite a gamble to take 250-350k (possibly even as 1099) with 2-3yrs partnership track when you could just take a $400k guaranteed job with good benefits. Now sure, you may eventually get 450k plus bonus, maybe even totaling 600k as a partner 3 years later, but there are a lot of stars that must align for that to happen.

The group has to be non-predatory, has to be healthy (good stable contracts and relationships with hospitals), have partners that want to maintain the group and grow (vs sell out because they are near the end of their careers or because the AMCs are coming at them continuously and they'd rather sell than get pushed out at the hospital contract level), they have to like you enough to make you partner, etc.

This is why as the new grad or potential new hire you need to ask the questions that seem pushy or as if we are overstepping. What does becoming partner mean? Does it just mean they no longer skim off the top or do I get voting rights, profit sharing, and full equal partnership? Are there super-partners? If so, that scares me as a sell off could happen at any time, even more so than it can anyways. Can I see the billing/accounts receivables for the last few recent partners and compare to what new hires are started at so I can truly see what my sweat equity buy in is?

And finally, the old adage that PP makes double or more what academics make does not appear to be even close to true from what I'm seeing. Now of course I haven't seen what full partners are clearing but it is striking to me that there are academic places offering 150k more to start than AMCs and 50-75k more to start than PP groups not even counting the benefits packages the academic departments offer.

I want to do PP, but the climate makes it a huge gamble which I'm not afraid to do.....for the right group.

Hospital employed positions (that I know) do not start at 400k. Of course you wouldnt stray from a sure thing if they offered 400k and a decent environment. Thats very high to start out in academics at 400k, and Im talking salary, not wierd relatives going for free and ominous benefits rolled in. These numbers are in terms of paycheck only

 

[anes121508]

Our stock provides ownership of 2 ASCs and a hospital. The base level of stock gives me ~0.15% ownership. I invested more and am currently ~1% owner. I have a lot of eggs in that basket, but it is a good basket currently. I did it to prepare for the day when anesthesia and other services fight over the money that is paid lump sum to hospital. I anticipate the hospital will keep more than they will give us, and I wanted to still get some.
Every quarter the extra money the hospital makes over expenses (and a certain amount of cash on hand holdback) gets distributed out to all partners. This set up is rare. So I get ~1% of the hospital profits per year. At the end, I can sell my stock for whatever it is worth at that time.
Every partnership offer and setup is going to be different, some would say I was screwed hard my first year, and they are probably right. However, for me it was a calculated risk that has allowed my situation to be far ahead of where I would have been had I taken that employed or academic job elsewhere.

Wow. Not sure if be able to understand exactly the set up as a new grad and take the leap like you did.

Its good that you are starting to think about this now. It will make your job search more meaningful. Keep in mind if you DONT engage in the path to ownership (which I agree can be sleezy and frustrating) you can keep your pride while they keep your 100-200k extra salary..

One takeaway from all of this discussion is that the terms "buy in" and "partnership" can mean very different things. Finding out what they mean is essential to understanding what you are getting into, but it isn't always easy to find out the true structure and finances of a group from the outside. Only after a certain time with the group will the actual truth be revealed to you, good or bad. So be flexible and dont move your kids/buy a house/leave a good job for this uncertainty....

Key questions: How much do partners make? Is there a buy in? If so how does it work? How many years to partner? How likely is it that Ill make partner after that time?

Partners usually make 500k ish in an anesthesia group
Buy ins work all different ways. Often just the years of underpaid labor are enough. Asking for $$ on top of that seems like a lot to me.
Usually 2-4 years to partner.
Usually some type of marker along the way that ensures you will be partner. (sign papers/vote after 1yr?)

I think the mystery starts to become more clear when you start talking actual numbers and working for the group... for example:

Your offers:
AMC 350k 4 calls/mo no increases or decreases or performance markers. possibly 25k more in ot
PP group A 250k 3 yrs 4 calls/mo to partner where partners make 500k
University 290k with slower pace and set pay increases unless you are really bad

With the PP group yes you are "giving up" 250k a year to the partners, or are you "giving up" 100k per year compared to the AMC (which is your next highest offer). That doesnt matter.
However you look at it, its your only path to the bigger money.

Now with this being said I have seen some very shady groups offer "jr partnership" of 350k or even lower for an undetermined amount of time until "sr partners" advance them which never happens for decades or ever. It all depends on the numbers. The numbers depend on your local job market comparing AMC, other PP, and university offers.

Great advice thanks. I think the long term play would be the pp given the earning potential down the road. The tricky part for some new grads is the fact that many of us have a high amount of debt at interest rates 6-7% so that 100k up front really helps (thankfully I don't have that type of debt). Financial discipline early on can help that as I believe the more money you have, the more you tend to spend.

 

[anes121508]

I like being bitter. It allows me to maintain a critical eye on the scam artists out there. Even if I was in the perfect job situation, I would still call out the bull$hit when I see it. Otherwise, I'm pretty happy with my life, so you don't have to worry there.

As the saying goes: "Fool me once, shame on you; fool me twice, shame on me."

Lol, I have to say you have a great point there.

 

[anes121508]

You are entitled to your own opinion but not your own facts.. The facts dont bear out what you are saying..

The predatorial anesthesia private groups is the RULE rather than the exception.

Exclusive contracts have ruined the specialty.

Maybe I said it wrong initially, but I definitely did not mean to say that the majority of pp groups are fair and benevolent. I was pointing out that there are exceptions to the rule based on the fact that some lucky people I know joined good groups and are happy.

 

[anes121508]

Hospital employed positions (that I know) do not start at 400k. Of course you wouldnt stray from a sure thing if they offered 400k and a decent environment. Thats very high to start out in academics at 400k, and Im talking salary, not wierd relatives going for free and ominous benefits rolled in. These numbers are in terms of paycheck only

There are AMC employed positions starting at 400k. Which makes new people think twice about 250k-300kX 2-3 yrs for the chance of higher earning potential, even if you found a fair group.

 

[GravelRider]

Maybe I said it wrong initially, but I definitely did not mean to say that the majority of pp groups are fair and benevolent. I was pointing out that there are exceptions to the rule based on the fact that some lucky people I know joined good groups and are happy.

If there is a partnership track or buy-in, you should walk away with a very clear understanding of what that means. There needs to be transparency because you are taking an expensive risk. You should have an idea of what your earning potential will be and how hard you will be working for that. You should be given tangible data to back that up. Forget all the other smoke and mirrors. If it sounds at all shady, then walk away because it probably is. Trust your gut.

I also stand by my statement that exclusive contracts have contributed to the demise of the specialty. It allowed people to make a lot of money for a couple decades, but in the long run it is terrible for the field.

 

[chocomorsel]

Hospital employed positions (that I know) do not start at 400k. Of course you wouldnt stray from a sure thing if they offered 400k and a decent environment. Thats very high to start out in academics at 400k, and Im talking salary, not wierd relatives going for free and ominous benefits rolled in. These numbers are in terms of paycheck only

Just go to gaswork and look at places like IN, or IA, or OH. You will see a few 400k plus employed positions.

 

[Hoya11]

Just go to gaswork and look at places like IN, or IA, or OH. You will see a few 400k plus employed positions.

I would never live there. Especially to make less than I would at my partner gig near a very desirebale city and where im from after only a few years at slightly lower pay.

It all depends on the numbers, sometimes the AMC makes sense, I personally would not consider those jobs for a second...

 

[nimbus]

I would never live there. Especially to make less than I would at my partner gig near a very desirebale city and where im from after only a few years at slightly lower pay.

It all depends on the numbers, sometimes the AMC makes sense, I personally would not consider those jobs for a second...

Agree.

I'm from one of those states and would never move back. But to each their own. There seems to be a widely held belief that desireable jobs can only be found in undesirable places but that's simply not true.

 

[aneftp]

The thing with AMCs to consider is that 400k seems great. If fully staffed (that a big if). Than work isn't too bad.

The real issue is taxation. Private groups can keep a pretax slush fund for CME, ,computers, cell phones (mine previous one was with 80k). Plus contribute say 34k (whatever the IRS limit up to 260k) pretax and u can put another 18/24k pretax depending on age.

So that income is heavily taxed between 250-400k with AMC cause they don't have that type of tax shelter.

 

[Ezekiel2517]

and another one. sf bay area group. http://finance.yahoo.com/news/amsurg-physician-services-division-sheridan-110000293.html

 

[PainDrain]

"Dr. Robert Pinsker, MD, JD, and President of Fidere Anesthesia Consultants, commented, “We were seeking a strategic partner to help meet the challenges of a changing U.S. healthcare market and strengthen the position of our physicians. After a thorough search, we selected Sheridan as the partner who would best help us to grow the unique programs we have established and position us to thrive in this challenging market. Sheridan’s resources, which include robust experience in anesthesiology and multiple complementary service lines, made them the obvious partner.”


Translation: We sold out to the highest bidder (Sheridan) because the group is aging and the senior partners are looking for some quick cash so they can retire. F-CK the younger generation, I got mine.

 

[bashwell]

I like being bitter. It allows me to maintain a critical eye on the scam artists out there. Even if I was in the perfect job situation, I would still call out the bull$hit when I see it. Otherwise, I'm pretty happy with my life, so you don't have to worry there.

As the saying goes: "Fool me once, shame on you; fool me twice, shame on me."

I thought it went like this:

 

[pgg]

Translation: We sold out to the highest bidder (Sheridan) because the group is aging and the senior partners are looking for some quick cash so they can retire. F-CK the younger generation, I got mine.

They built and/or acquired something of value and sold it prior to retirement to someone who wanted it and had money. The horror.

Unless they lied to any members of the "younger generation" or breached a contract, I can't bring myself to fault them.

When I'm on the edge of retirement, I plan to sell the things of value I have acquired over my lifetime, too.

By now every member of the "younger generation" has been well and truly warned that predatory practices exist and can take steps to minimize their risk of unexpectedly getting hosed by a bad contract and unscrupulous group.

Yes, the days of the mid-90s when the least competent rejects of every med school in the country could get an anesthesia residency and then accidentally stumble into a booming market and then get rich are over. But don't let your disappointment in being born 20 years too late turn you into some kind of bitter anti-capitalist. Be careful where you choose to work, live beneath your means, and be glad you're not soaking wet in Haiti right now.

 

[GravelRider]

They built and/or acquired something of value and sold it prior to retirement to someone who wanted it and had money. The horror.

Unless they lied to any members of the "younger generation" or breached a contract, I can't bring myself to fault them.

When I'm on the edge of retirement, I plan to sell the things of value I have acquired over my lifetime, too.

By now every member of the "younger generation" has been well and truly warned that predatory practices exist and can take steps to minimize their risk of unexpectedly getting hosed by a bad contract and unscrupulous group.

Yes, the days of the mid-90s when the least competent rejects of every med school in the country could get an anesthesia residency and then accidentally stumble into a booming market and then get rich are over. But don't let your disappointment in being born 20 years too late turn you into some kind of bitter anti-capitalist. Be careful where you choose to work, live beneath your means, and be glad you're not soaking wet in Haiti right now.

That's kind of funny because these noble capitalists really benefitted from a pretty anti-capitalist system. As a matter of fact, anesthesiology is probably one of the least capitalist specialties. Exclusive contracts are inherently anti-capitalist and that is what is being sold here. Where is the free market competition? When can a patient or a surgeon choose which anesthesiology group gets consulted for their procedure?

When I was a hospitalist, I could consult whichever cardiology group I wanted (provided they had hospital privileges, of course). Sometimes a patient or primary care doc had a request for a certain group. Sometimes it was up to me, at which point I would choose the group that provided prompt service and were knowledgeable.

 

[IlDestriero]

You can compete for the contract every 3 years or so. That's one of the reasons they decide to sell out for guaranteed money. Their big corporation is built on a foundation of sand and goodwill, and there's a hurricane on the horizon. Maybe it will veer away, maybe not.


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Il Destriero

 

[PainDrain]

They built and/or acquired something of value and sold it prior to retirement to someone who wanted it and had money. The horror.

Unless they lied to any members of the "younger generation" or breached a contract, I can't bring myself to fault them.

When I'm on the edge of retirement, I plan to sell the things of value I have acquired over my lifetime, too.

By now every member of the "younger generation" has been well and truly warned that predatory practices exist and can take steps to minimize their risk of unexpectedly getting hosed by a bad contract and unscrupulous group.

Yes, the days of the mid-90s when the least competent rejects of every med school in the country could get an anesthesia residency and then accidentally stumble into a booming market and then get rich are over. But don't let your disappointment in being born 20 years too late turn you into some kind of bitter anti-capitalist. Be careful where you choose to work, live beneath your means, and be glad you're not soaking wet in Haiti right now.

I think you, like far to many in this country, confuse capitalism with rational self-interest. Capitalism and morality are not mutually exclusive.

 

[Robotic Wis-Hipple]

The fear or risk aversion from said younger generation is not necessarily indicative of some woe is me attitude or the oft blamed entitlement. I completely understand the forces in play here. I don't fault any entrepreneur that works within the system to build something for selling when it's the right time, that's their right, or more specifically was likely the goal of their enterprise from the beginning.

My point is there are a lot of groups that aren't exactly full disclosure in their hiring/recruitment because they know that new grads aren't gonna just sign up for a group that's looking to sell, obviously that's bad for recruitment. Add those to the groups simply existing in this current overall market which legitimately may not know that they will be bought out, forced out, or look to capitalize before the foundation crumbles in the period of the partner track they sold you and you have likely the majority of groups available. I mean even the huge groups, grown upon the predication that their size gives them leverage and power to avoid losing contracts etc are selling/merging, some for market forces reasons, others for super partner benefit (which again, I'd agree is their right to cash out on what they built before it turns to nothing)

So this leaves 3 choices (4 if you consider locums); sign employed position, sign with a small group and hope you can avoid losing contracts or getting underbid by the AMC du jour, or sign with a power group and hope the super partners are bullish on the bubble. You're either leaving money on the table or risking doing the same.

 

[pgg]

I think you, like far to many in this country, confuse capitalism with rational self-interest. Capitalism and morality are not mutually exclusive.

OK

Forget the capitalism angle. What do you think is irrational about the partners selling out for guaranteed money on the cusp of retirement?

You're acting angry, like you think they owe you something. They don't owe you anything more than to honor the terms of whatever contract they offered you and you accepted.

What I object to is the way you're superimposing some kind of fuzzy morality judgement on these guys who sold something they owned, but didn't cut you in on their gains out of the goodness of heir hearts.

 

[Psai]

Something is given to you and you think that not only do you own it, but can sell the future rights for your own personal gain. When you're selling out the future of the specialty, you are selling something you don't own. Isn't it enough that I'm paying for your social security and medicare without paying for the rest of your retirement with my future salary?

 

[deleted126335]

Something is given to you and you think that not only do you own it, but can sell the future rights for your own personal gain. When you're selling out the future of the specialty, you are selling something you don't own. Isn't it enough that I'm paying for your social security and medicare without paying for the rest of your retirement with my future salary?

Something is given to you:

All life is an exchange. Nobody gives nobody nothing.

 

[deleted162650]

As has already been alluded to, the details of the "buy-in" are infinitely more important than the presence or absence of a "buy-in." Some groups are shady, some are honest. It's up to you and the connections you've hopefully made to figure out who you're dealing with. If it's a quality group offering a legit partner track position, then everything should be explicitly laid out in the contract:

-Duration of track
-Pay during track
-What happens if group is sold
-What are provisions for termination (with/without cause)
-Malpractice coverage

They should also be up front with you with regards to how many people have started the track and failed to become partner. They should provide contact info for people who have left the group. You should know how many current members are partners and if all partners are equal. Essentially, nothing should be taken on good faith alone, and nothing should be left up to nebulous "maybe you'll make partner at the end of the track if we feel like it and you've shown adequate fellatio skills BS"

I wouldn't let the presence of a track scare you off if it's the right group in the right locale doing the right kind of work with the right kind of colleagues. Think of a PP group like an exclusive club and the buy-in is the membership fee. Is belonging to that club worth the membership fee? Is this really a club you want to be a part of, or would you rather be part of crappier club with no membership. You wanna play at Augusta or the local public course. Is the fraternity worth the rushing/hazing. All these are personal questions and a lot probably depends on what your options are.

From the group's view-point, the track is a way to protect and insulate your group. It provides for a vetting period for them to see if a new hire is a good clinician, a good human, and a good fit (I agree this shouldn't take more than a year and excessively long tracks are abusive). A quality group also wants stability and not a revolving door of people just looking to come through, make a few bucks, and move on. People are more likely to stay if they are financially/temporally invested with the group.


As to this whole business of exclusive contracts being the Devil's work, have you ever worked at a facility without an exclusive contract for anesthesia?? My first gig was like that. Open staffing with 2 groups splitting the anesthesia department. Not all it's cracked up to be. Talk about herding cats. Talk about competition for cases (despite an exceedingly fair scheduling/reimbursement system). Talk about not being able to get rid of a problem anesthesiologist (both clinically and interpersonally) unless they do something so heinous as to actually get kicked off the medical staff which is nearly impossible. Talk about an inefficient system since taking over cases gets messy from a billing standpoint. Talk about not being able to negotiate with the hospital who will play each group off the other and then throw a price-fixing lawsuit at you when you try to negotiate the same fair deal for both groups. An anesthesia department runs so much better when everyone plays for the same team. Contracts may be exclusive, but they aren't indefinite. Think you can do it better, then make a run on the contract. It wouldn't be the first time it's happened. Maybe then you will appreciate the (unreimbursed) work and time it takes to not only secure but also maintain an anesthesia contract. You'll understand the value in a functional anesthesia group and why as the owner of a successful business, you have every right to sell it if you see fit.

 

[Consigliere]

Suns out, guns out.

 

[GravelRider]

OK

Forget the capitalism angle. What do you think is irrational about the partners selling out for guaranteed money on the cusp of retirement?

You're acting angry, like you think they owe you something. They don't owe you anything more than to honor the terms of whatever contract they offered you and you accepted.

What I object to is the way you're superimposing some kind of fuzzy morality judgement on these guys who sold something they owned, but didn't cut you in on their gains out of the goodness of heir hearts.

But it's ok when these old hacks profit off our work? I'm not asking for the money they earned, I just want to keep the money that I earn.

I am sick of hearing about how these anesthesia sellouts are some philosophical martyrs for the cause of capitalism. Let's call it what it really is...greed and fear. In that order. The anger is directed at a generation of physicians that only saw dollar signs and have left a specialty in the hands of a bunch of businessmen that only see us as ways to turnover ORs quickly so we can line their pockets with more money. We (physicians) are now a means to an end. I think anyone would be angry about that.

 

[caligas]

[/QUOTE]

As has already been alluded to, the details of the "buy-in" are infinitely more important than the presence or absence of a "buy-in." Some groups are shady, some are honest. It's up to you and the connections you've hopefully made to figure out who you're dealing with. If it's a quality group offering a legit partner track position, then everything should be explicitly laid out in the contract:

-Duration of track
-Pay during track
-What happens if group is sold
-What are provisions for termination (with/without cause)
-Malpractice coverage

They should also be up front with you with regards to how many people have started the track and failed to become partner. They should provide contact info for people who have left the group. You should know how many current members are partners and if all partners are equal. Essentially, nothing should be taken on good faith alone, and nothing should be left up to nebulous "maybe you'll make partner at the end of the track if we feel like it and you've shown adequate fellatio skills BS"

I wouldn't let the presence of a track scare you off if it's the right group in the right locale doing the right kind of work with the right kind of colleagues. Think of a PP group like an exclusive club and the buy-in is the membership fee. Is belonging to that club worth the membership fee? Is this really a club you want to be a part of, or would you rather be part of crappier club with no membership. You wanna play at Augusta or the local public course. Is the fraternity worth the rushing/hazing. All these are personal questions and a lot probably depends on what your options are.

From the group's view-point, the track is a way to protect and insulate your group. It provides for a vetting period for them to see if a new hire is a good clinician, a good human, and a good fit (I agree this shouldn't take more than a year and excessively long tracks are abusive). A quality group also wants stability and not a revolving door of people just looking to come through, make a few bucks, and move on. People are more likely to stay if they are financially/temporally invested with the group.


As to this whole business of exclusive contracts being the Devil's work, have you ever worked at a facility without an exclusive contract for anesthesia?? My first gig was like that. Open staffing with 2 groups splitting the anesthesia department. Not all it's cracked up to be. Talk about herding cats. Talk about competition for cases (despite an exceedingly fair scheduling/reimbursement system). Talk about not being able to get rid of a problem anesthesiologist (both clinically and interpersonally) unless they do something so heinous as to actually get kicked off the medical staff which is nearly impossible. Talk about an inefficient system since taking over cases gets messy from a billing standpoint. Talk about not being able to negotiate with the hospital who will play each group off the other and then throw a price-fixing lawsuit at you when you try to negotiate the same fair deal for both groups. An anesthesia department runs so much better when everyone plays for the same team. Contracts may be exclusive, but they aren't indefinite. Think you can do it better, then make a run on the contract. It wouldn't be the first time it's happened. Maybe then you will appreciate the (unreimbursed) work and time it takes to not only secure but also maintain an anesthesia contract. You'll understand the value in a functional anesthesia group and why as the owner of a successful business, you have every right to sell it if you see fit.

 

[pgg]

But it's ok when these old hacks profit off our work? I'm not asking for the money they earned, I just want to keep the money that I earn.

Is that any different than anyone, anywhere, who goes to anybody else, anywhere else looking for a job?

I am sick of hearing about how these anesthesia sellouts are some philosophical martyrs for the cause of capitalism.

Let's call it what it really is...greed and fear. In that order.

It's no more greedy or fearful than selling your Apple stock because you think the iPhone is a fad. Hardly worthy of the contempt you show.

The anger is directed at a generation of physicians that only saw dollar signs and have left a specialty in the hands of a bunch of businessmen that only see us as ways to turnover ORs quickly so we can line their pockets with more money.

This is where you confuse cause and effect. The businessmen were coming, regardless. Physicians didn't come up with bundled payments. Physicians didn't cause the cost of healthcare to explode (our salaries are less than 1/10th the cost of healthcare in the US). Physicians didn't conjure the Affordable Care Act. Physicians didn't invent CMS and hire the werewolves and vampires at the Joint Commission. Businessmen did all those things.

The businessmen came because the system was bloated, full of money-extraction opportunities for middlemen. It is increasingly bogged down by regulations and certifying agencies, and physicians were (and are) generally unmotivated and ill-equipped to handle it all.

We (physicians) are now a means to an end. I think anyone would be angry about that.

I share your anger about that. I hate being referred to as a "provider" ...

But the biggest deficiency in your sense of perspective is that it's not just anesthesia, it's all of medicine ... and it's not just medicine, but the entire economy. You're angry that the Anesthesia Dream isn't what you thought it would be? Get in line behind the other 300 million people here who are having more trouble realizing the American Dream than their elders.

 

[Mman]

But it's ok when these old hacks profit off our work? I'm not asking for the money they earned, I just want to keep the money that I earn.

So what happens when the group you work for collects a far higher $$$ amount than you could on your own for your work. Did you earn that money yourself? Or did their long term negotiated/contracted rate help earn that money? Because in my eyes, the only money you actually earn yourself is what you could collect on your own as an independent contractor which is probably approaching CMS rates. Anything beyond that absolutely requires a group to negotiate collectively.

 

[skypilot]

They built and/or acquired something of value and sold it prior to retirement to someone who wanted it and had money. The horror.

Unless they lied to any members of the "younger generation" or breached a contract, I can't bring myself to fault them.

When I'm on the edge of retirement, I plan to sell the things of value I have acquired over my lifetime, too.

By now every member of the "younger generation" has been well and truly warned that predatory practices exist and can take steps to minimize their risk of unexpectedly getting hosed by a bad contract and unscrupulous group.

Yes, the days of the mid-90s when the least competent rejects of every med school in the country could get an anesthesia residency and then accidentally stumble into a booming market and then get rich are over. But don't let your disappointment in being born 20 years too late turn you into some kind of bitter anti-capitalist. Be careful where you choose to work, live beneath your means, and be glad you're not soaking wet in Haiti right now.

Still feels like a group of doctors who live and work and raise their families in the community selling out to a corporation in Texas or Florida whose only concern is fat bonuses for executives and shareholders.

 

[deleted162650]

View attachment 209589[/QUOTE]

Where'd you find that picture of @Twiggidy?

I kid I kid.

 

[deleted171991]

Take a well-paid employee position. When you find a better one (which any employee should continuously look for), ask them to make you full partner with reasonable buy-in (about 6 -12 months of partner-employee income difference) or leave. Just like in a relationship: you either move on after a while, or you get married.

No "partnership track", no being screwed with for 3-4 years for a promise that can be withdrawn based on a lot of fine print reasons.

Even better, avoid this specialty altogether (if still a student).

 

[sevoflurane]

Take a well-paid employee position. When you find a better one (which any employee should continuously look for), ask them to make you full partner with reasonable buy-in (about 6 -12 months of partner-employee income difference) or leave. Just like in a relationship: you either move on after a while, or you get married.

No "partnership track", no being screwed with for 3-4 years for a promise that can be withdrawn based on a lot of fine print reasons.

Even better, avoid this specialty altogether (if still a student).

Not sure if this is such a great idea FFP.
Good groups still exist and are worth the buy in. 6-12 months is historically not acurate for good goups (outside of the 90's).
I see where you are coming from though.

 

[sevoflurane]

Is that any different than anyone, anywhere, who goes to anybody else, anywhere else looking for a job?







It's no more greedy or fearful than selling your Apple stock because you think the iPhone is a fad. Hardly worthy of the contempt you show.



This is where you confuse cause and effect. The businessmen were coming, regardless. Physicians didn't come up with bundled payments. Physicians didn't cause the cost of healthcare to explode (our salaries are less than 1/10th the cost of healthcare in the US). Physicians didn't conjure the Affordable Care Act. Physicians didn't invent CMS and hire the werewolves and vampires at the Joint Commission. Businessmen did all those things.

The businessmen came because the system was bloated, full of money-extraction opportunities for middlemen. It is increasingly bogged down by regulations and certifying agencies, and physicians were (and are) generally unmotivated and ill-equipped to handle it all.



I share your anger about that. I hate being referred to as a "provider" ...

But the biggest deficiency in your sense of perspective is that it's not just anesthesia, it's all of medicine ... and it's not just medicine, but the entire economy. You're angry that the Anesthesia Dream isn't what you thought it would be? Get in line behind the other 300 million people here who are having more trouble realizing the American Dream than their elders.

Always a good voice of reason.

 

[repititionition]

Even better, avoid this specialty altogether (if still a student).

What would you do if you were a 3rd year medical student with an application competitive for any specialty, but categorically uninterested in /unwilling to be a surgeon?

 

[sevoflurane]

What would you do if you were a 3rd year medical student with an application competitive for any specialty, but categorically uninterested in /unwilling to be a surgeon?

Derm/Path

 

[sevoflurane]

Interventional/EP Cards or Interverntional Rads is where I personally would go though.

edit: 10 years ago... it would still be anesthesia.

 

[deleted171991]

What would you do if you were a 3rd year medical student with an application competitive for any specialty, but categorically uninterested in /unwilling to be a surgeon?

A good student could get into a good medical subspecialty, and do better long-term than with anesthesia. In the eyes of the bean counters, anesthesiologists are to surgeons as paralegals are to attorneys. Or as liabilities which cost money vs assets which make money. The more money an employee brings in the more valuable she is, and the other way round. There is a much higher chance of making partner or, at least, being respected as doctors. I was more of a doctor as a CCM fellow than as an attending anesthesiologist, especially in the MICU.

In the era of bundled payments, anesthesiologists will be 100% just a cost center, not a moneymaker. We will share our slice of the pie with the scrub nurse, the anesthesia tech, the cleaning staff etc., and have to fight for it much harder than nowadays. (There was an awesome presentation at the ASA meeting last year about how surgeons, when polled, would give us 3 times less than what we get today.) Not only that, but we will be a captive audience given the job market. So personally I think that, as a specialty, we are screwed, long term. Most patients don't even know that we are doctors or how risky and stressful is what we do. We are just surgical helpers.

 

[Carbocation1]

Gas docs < 40 yo still are in upper echelon of earnings, rank #3 behind Ortho and Derm. How can this be explained in light of AMCs/decline of PP?

Medscape Young Physicians Compensation Report 2016

 

[Carbocation1]

No jobs in IC/EP cardiology despite 8 years of long training post medical school: https://www.reddit.com/r/medicine/comments/55to2d/seeking_first_job_post_interv_cardiology/

"I think our expectations are a little blown as we've been following postings for years on healthecareers.com and with only 6 months left until her fellowship is completed... Do we need to bang down their doors, possibly go above their heads and reach out to hospital administrators? I don't know how wise it is to show that level of desperation, so I guess just wait and see who responds? There is always locums."

"I'm also in a highly sub-specialized field with a notoriously limited job market, and it sucks. After ~10 years of sacrifices, you (appropriately) expect to feel like a bit of a commodity when you finish training."