Different Question about Hours

[Got Em]

Hey guys, I didn't see this anywhere on the forum. From what I've read, a typical setting requires 96-140 hours per month, even with places requiring 168 hours for new grads in some locations. My question is when everyone says "hours per month", do they mean over each actual month or over a 28 day period? 28 days sounds logical to me, but I'm not sure. Thank you.

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[Birdstrike]

Calendar month. One man's opinion:

Expect the high end of that scale for a new grad in most community jobs. Expect to be promised "X" and show up to find it's "X + 20%" until "we get fully staffed," which could happen soon or never.

There's a shortage of EPs.

Pro- Job security.

Con- Pressure to always work more than desired and potential burnout.

 

[Got Em]

Calendar month. One man's opinion:

Expect the high end of that scale for a new grad in most community jobs. Expect to be promised "X" and show up to find it's "X + 20%" until "we get fully staffed," which could happen soon or never.

There's a shortage of EPs.

Pro- Job security.

Con- Pressure to always work more than desired and potential burnout.

I know that there are plenty of jobs in Texas, but are you seeing this in most areas of the country as well? Do you think much of this shortage is due to the exponential increase in free standings? My concern is that once this model becomes saturated in the next 5 years, demand will go down quite a bit. What is your take on this? Thanks.

 

[Birdstrike]

I know that there are plenty of jobs in Texas, but are you seeing this in most areas of the country as well? Do you think much of this shortage is due to the exponential increase in free standings? My concern is that once this model becomes saturated in the next 5 years, demand will go down quite a bit. What is your take on this? Thanks.

I don't think anyone is predicting an over-supply of ER doctors in any of our lifetimes. If anyone is, I'd be interested in reading it.

Even if you had too many ER doctors, and too many ERs all of a sudden, I don't doubt that there would be patients flocking to those no-wait-time ERs with all those, bored, underworked ER doctors desperate for patients.

Don't over think this one. There will be no "unemployed-ER doctor problem" in our lifetimes.

 

[The White Coat Investor]

Hey guys, I didn't see this anywhere on the forum. From what I've read, a typical setting requires 96-140 hours per month, even with places requiring 168 hours for new grads in some locations. My question is when everyone says "hours per month", do they mean over each actual month or over a 28 day period? 28 days sounds logical to me, but I'm not sure. Thank you.

I try to avoid jobs with "requirements" having had one before (they required me to go to the Middle East and wear camouflage). I now prefer to own a business, work as much or as little as I want, and keep my share of anything extra the business generates.

I work fifteen 8 hour shifts per month, so that's 120 hours per 28, 29, 30, or 31 days, or about 28 hours per week on average. Most shops schedule by the month, but occasionally I see one that does it on a 28 day schedule. It's usually a residency program.

 

[Got Em]

I try to avoid jobs with "requirements" having had one before (they required me to go to the Middle East and wear camouflage). I now prefer to own a business, work as much or as little as I want, and keep my share of anything extra the business generates.

I work fifteen 8 hour shifts per month, so that's 120 hours per 28, 29, 30, or 31 days, or about 28 hours per week on average. Most shops schedule by the month, but occasionally I see one that does it on a 28 day schedule. It's usually a residency program.

So you're suggesting for us to go the partnership route in a private group? I read somewhere that <1/3 of EM physicians are currently in private practice. With CMGs taking contracts left and right, I hope this route is still available in 6 years. Maybe there is another way?

 

[EctopicFetus]

As has been discussed the SDG is great. The locums is ok. Depending on the situation the CMG may be tolerable.

Im with WCI..

Also to anyone who is worried about an oversupply of EPs.. dont..

According to https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf

Page 16.. EPs 55 and older make up 1/3 of ED docs. Thats way overrepresented. I would imagine the avg age of a new grad is like 30-33. Sure there are some who are older but not many.

Basic math says about 1/3 of our profession will retire in the next 10 years. I havent seen too many 65 yr old ED docs. Just sayin.

 

[Groove]

You can always negotiate your minimum shifts/mo. 14/mo seems standard as was in both vanilla CMG contracts that I've signed. I had the latest one change it to 12/mo though I work around 13-14, 9-11h shifts per month which usually works out to 135h or so. We always have shifts available to pick up, so last month I worked 18. Whereas, I only worked 12 one month where I needed to take extra time off. There's two sides of the coin... You don't want to get overworked and pressured to pick up all these extra shifts, but you also want to get enough shifts every month, so be careful when you negotiate fewer shifts. In my case, luckily there's usually always enough to pick up when you want to earn some extra $$$ that month but if I put in a request for 18 shifts, I wouldn't get it. Everyone seems to be given 13-14/mo standard. 15-16 is prob my sweet spot but I'll be honest... 13-14 is nice. I'm well rested and have plenty of time to enjoy life while still enjoying a good salary.

The whole CMG vs SDG vs Hospital Employee seems to evoke heated opinions but if you look at the numbers and the trends, SDG is going the way of the Dodo. CMG, and now, even Hospital Employee models are proliferating. I think it's going to be increasingly difficult for democratic groups to compete with the raw resources and operational efficiency of a CMG. I'm getting paid more than I was being offered by what I considered a nice SDG gig on the other side of my current state. That's the salary described to me after the 2y buy in minus profit sharing though I was told that the last year there wasn't enough in the pot for much profit sharing as they had taken on some new contracts at a loss. I had two colleagues that I worked with at my last CMG that took a MASSIVE pay cut during a buy in only to have the group disbanded and gobbled up by a CMG 2 months before making partner. I have a locums guy that I occasionally work with who had the same thing happen. The whole "buy in" for X years while we give you the crappy shifts and overload you with the elusive promise of partner just rubs me the wrong way though I agree that I see more than a few advantages. I mean, have you seen the termination clauses for some SDG groups? I haven't seen many but this particular one had so many vague and confusing criteria that you might as well have said "If we decide that we don't like you after 3 years, we can fire you on a moment's notice. If you fire us... wait 4 months and write a letter." Then there are the strings attached. After you make partner, you are heavily incentivized to stay....forever. I mean, you don't even have a good feel for a new hospital environment until you've been at a place...what, 6 months? 8? Is anyone going to tell me that ED and hospital politics don't change over time? Good environments don't become malignant? Part of the enjoyment in being an EM doc for me is the mobility. I have the freedom to work wherever I want, whenever I want at almost a moment's notice. If there is absolutely anything I don't like at my current gig, I can get hired at another hospital and be on their schedule in a heartbeat. CMG's can be criticized, but look.... it's the docs that are the lifeblood of the business. You have to keep them happy to some extent which usually equates to fair wages. If I get hired by one, they have to compete with all the rest who are looking to hire me. I can hit the ground running making exactly the same as the guy who's been there 10 years and we all work the same shifts. No senior partners working only day shifts while the new guys take nights. Everything is equal and I really enjoy that. Obviously the ED director is going to have the best schedule but I expect that and he needs it.

Also, have you tried getting sign on bonuses with SDGs? Good luck. I was offered 10K in moving expenses with much reluctance as "It's all coming out of our pockets." Every CMG I've worked for down here has made very nice offers on 2y contracts. Want to negotiate another sign on after your 2y is over? Go for it. You have to factor the sign on bonuses into the salary equations also.

Personally, I've been more than happy with my CMG experiences so far and don't see that changing anytime soon unless health insurance premiums go through the roof.

 

[Got Em]

As has been discussed the SDG is great. The locums is ok. Depending on the situation the CMG may be tolerable.

Im with WCI..

Also to anyone who is worried about an oversupply of EPs.. dont..

According to https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf

Page 16.. EPs 55 and older make up 1/3 of ED docs. Thats way overrepresented. I would imagine the avg age of a new grad is like 30-33. Sure there are some who are older but not many.

Basic math says about 1/3 of our profession will retire in the next 10 years. I havent seen too many 65 yr old ED docs. Just sayin.

You can always negotiate your minimum shifts/mo. 14/mo seems standard as was in both vanilla CMG contracts that I've signed. I had the latest one change it to 12/mo though I work around 13-14, 9-11h shifts per month which usually works out to 135h or so. We always have shifts available to pick up, so last month I worked 18. Whereas, I only worked 12 one month where I needed to take extra time off. There's two sides of the coin... You don't want to get overworked and pressured to pick up all these extra shifts, but you also want to get enough shifts every month, so be careful when you negotiate fewer shifts. In my case, luckily there's usually always enough to pick up when you want to earn some extra $$$ that month but if I put in a request for 18 shifts, I wouldn't get it. Everyone seems to be given 13-14/mo standard. 15-16 is prob my sweet spot but I'll be honest... 13-14 is nice. I'm well rested and have plenty of time to enjoy life while still enjoying a good salary.

The whole CMG vs SDG vs Hospital Employee seems to evoke heated opinions but if you look at the numbers and the trends, SDG is going the way of the Dodo. CMG, and now, even Hospital Employee models are proliferating. I think it's going to be increasingly difficult for democratic groups to compete with the raw resources and operational efficiency of a CMG. I'm getting paid more than I was being offered by what I considered a nice SDG gig on the other side of my current state. That's the salary described to me after the 2y buy in minus profit sharing though I was told that the last year there wasn't enough in the pot for much profit sharing as they had taken on some new contracts at a loss. I had two colleagues that I worked with at my last CMG that took a MASSIVE pay cut during a buy in only to have the group disbanded and gobbled up by a CMG 2 months before making partner. I have a locums guy that I occasionally work with who had the same thing happen. The whole "buy in" for X years while we give you the crappy shifts and overload you with the elusive promise of partner just rubs me the wrong way though I agree that I see more than a few advantages. I mean, have you seen the termination clauses for some SDG groups? I haven't seen many but this particular one had so many vague and confusing criteria that you might as well have said "If we decide that we don't like you after 3 years, we can fire you on a moment's notice. If you fire us... wait 4 months and write a letter." Then there are the strings attached. After you make partner, you are heavily incentivized to stay....forever. I mean, you don't even have a good feel for a new hospital environment until you've been at a place...what, 6 months? 8? Is anyone going to tell me that ED and hospital politics don't change over time? Good environments don't become malignant? Part of the enjoyment in being an EM doc for me is the mobility. I have the freedom to work wherever I want, whenever I want at almost a moment's notice. If there is absolutely anything I don't like at my current gig, I can get hired at another hospital and be on their schedule in a heartbeat. CMG's can be criticized, but look.... it's the docs that are the lifeblood of the business. You have to keep them happy to some extent which usually equates to fair wages. If I get hired by one, they have to compete with all the rest who are looking to hire me. I can hit the ground running making exactly the same as the guy who's been there 10 years and we all work the same shifts. No senior partners working only day shifts while the new guys take nights. Everything is equal and I really enjoy that. Obviously the ED director is going to have the best schedule but I expect that and he needs it.

Also, have you tried getting sign on bonuses with SDGs? Good luck. I was offered 10K in moving expenses with much reluctance as "It's all coming out of our pockets." Every CMG I've worked for down here has made very nice offers on 2y contracts. Want to negotiate another sign on after your 2y is over? Go for it. You have to factor the sign on bonuses into the salary equations also.

Personally, I've been more than happy with my CMG experiences so far and don't see that changing anytime soon unless health insurance premiums go through the roof.

Thank you guys so much for these informative posts!

 

[gman33]

The discussion regarding SDGs losing contracts is an interesting question for a new grad.
In the area where I am looking for a job, there are a few nice SDG gigs available.
By nice, I mean they would nice jobs as a partner.

Becoming a partner is a long process of paying your dues.
The place that would be the best for me in the long term has a 5 year pre-partner status.
I'd hate to be there for 5 years and then have the contract pulled.

I think I would have a hard time signing up for that job in the current environment.

 

[Apollyon]

The discussion regarding SDGs losing contracts is an interesting question for a new grad.
In the area where I am looking for a job, there are a few nice SDG gigs available.
By nice, I mean they would nice jobs as a partner.

Becoming a partner is a long process of paying your dues.
The place that would be the best for me in the long term has a 5 year pre-partner status.
I'd hate to be there for 5 years and then have the contract pulled.

I think I would have a hard time signing up for that job in the current environment.

5 year partner plan? Umm, yeah...I don't think so.

 

[EctopicFetus]

Agreed. 5 years to make partner is too long. I think 3 years is pushing it. 1 year is reasonable.

I would make sure you get all the details of that job. I would say that anyone who can get people to work in a 5 year pre-partner gig must have some great payoff.

I would really be worried but to each their own. What I know is the CMG is not the answer.

The discussion regarding SDGs losing contracts is an interesting question for a new grad.
In the area where I am looking for a job, there are a few nice SDG gigs available.
By nice, I mean they would nice jobs as a partner.

Becoming a partner is a long process of paying your dues.
The place that would be the best for me in the long term has a 5 year pre-partner status.
I'd hate to be there for 5 years and then have the contract pulled.

I think I would have a hard time signing up for that job in the current environment.

 

[EctopicFetus]

Ill say this.. its obivous and basic to me.

For some people the CMG is best. I get that. I also dont discount the benefits (Punch in-punch out, no contract worries etc.)

There is a real price for this. The CMGs are in it to make money. They skim 25-30%. I think a poorly run SDG is the problem. The reason the SDGs worry is that if a CMG takes the contract pay goes down by a large amount and control over the work environment is lost.

I am confident if i went to work for a cmg my income would be cut by more than the 25-30%. To me this is my "pay" for all the extra stuff I do.

 

[Birdstrike]

Agreed. 5 years to make partner is too long. I think 3 years is pushing it. 1 year is reasonable.

I would make sure you get all the details of that job. I would say that anyone who can get people to work in a 5 year pre-partner gig must have some great payoff.

I would really be worried but to each their own. What I know is the CMG is not the answer.

I agree. 5 years to partnership is abso-flipping-lutely outrageous. I could see it in a specialty where it takes years to build a practice and clientele (small Subspecialty) where there's an investment in equipment, or real estate (urgent care or surgery center) but in Emergency Medicine, where you walk in day one to an exploding geyser of patient flow, it's ridiculous. They're milking, milking, milking you for that whole time, suckling from that udder attached to your bank account. There is a delay of 3-6 months for a specific ER doctor's collections to come in, due to insurance delays, credentialling and such, but 5 years? No way.

There's no way they can tell you it takes 5 years to turn a profit on you. That should happen well within a year in Emergency Medicine. That's not to mention the high likelihood nowadays, of these SDGs contracts falling to CMGs, where you could lose any promise of making partner, like others have said.

5 years? Come on.

I'd really like to know what's so great about any specific job that they expect anyone to wait five years to get?

This is why you'd set up a 5 year to partnership track:

Create a scenario that no one wants to tolerate for greater than five years, expect a high turnover rate, so that very few ever make partner, which creates a scenario where the fish at the top of the food chain get fat and the little fish at the bottom have a feeding freezing over a few leftover scraps while starving. Then when the owners get ready to retire, the group is turned over to a CMG, with a fee to buy out your non-compete. All the cash goes to the fat fish, nothing the the little fish. The fat fish retire and the little fish go to work for the CMG.

"5 years to partner. Hiring now! "

 

[gman33]

The job is at a very good community hospital.
Partners make more than most other places in the area due to payer mix.
Part of the long prepartner status is so they can get you to work nights.
Like all nights if I'm not mistaken.

The benefit is that partners make $$ and don't work nights.

They pay pretty well as a prepartner from what I was told.
Too many things can happen in 5 years that would be out of my control.

I'll pass on this great opportunity.

 

[EctopicFetus]

The job is at a very good community hospital.
Partners make more than most other places in the area due to payer mix.
Part of the long prepartner status is so they can get you to work nights.
Like all nights if I'm not mistaken.

The benefit is that partners make $$ and don't work nights.

They pay pretty well as a prepartner from what I was told.
Too many things can happen in 5 years that would be out of my control.

I'll pass on this great opportunity.

Ill say this. I CHOSE to work nights at my SDG gig. It was set up to make nights attractive due to pay diff. I also know of some folks in ultra competitive locations who have to work nights to make it.

If the pay is good and the job tolerable the SDG sounds better no? 5 years is insane.. I would say if it is 1-2 years til "partner" the rest until they make you whole with money its a different story.

I know of jobs where in years 1 and 2 the income is subpar but break even is mid year 3 due to healthy bonuses. After your 3rd year you are better off than a CMG.

Curious GMAN what state?

 

[Apollyon]

The job is at a very good community hospital.
Partners make more than most other places in the area due to payer mix.
Part of the long prepartner status is so they can get you to work nights.
Like all nights if I'm not mistaken.

The benefit is that partners make $$ and don't work nights.

They pay pretty well as a prepartner from what I was told.
Too many things can happen in 5 years that would be out of my control.

I'll pass on this great opportunity.

All nights for 5 years? That is just insane.

I mean, if you are making good money as a non-partner, you can consider it. Then, if they don't stab you in the back, it's a big bonus in 5 years.

 

[The White Coat Investor]

As I recall, Ectopic's partnership track was 5 years. But I agree, that's too long. 1 year is plenty of time to know if you want to be partners with someone, both ways. Our group is two years. But if someone has such a good thing going (job, pay, location etc) that people are willing to sign on for a 5 year partnership track....hard to blame them for implementing it. It's a much bigger deal now than it used to be since SDGs are under constant threat from CMGs. But which is worse? A 5 year track where you make 90% of what a partner makes or a 2 year track where you make 40% of what a partner makes? There's more to the equation than just the length of the partnership.

 

[Birdstrike]

As I recall, Ectopic's partnership track was 5 years. But I agree, that's too long. 1 year is plenty of time to know if you want to be partners with someone, both ways. Our group is two years. But if someone has such a good thing going (job, pay, location etc) that people are willing to sign on for a 5 year partnership track....hard to blame them for implementing it. It's a much bigger deal now than it used to be since SDGs are under constant threat from CMGs. But which is worse? A 5 year track where you make 90% of what a partner makes or a 2 year track where you make 40% of what a partner makes? There's more to the equation than just the length of the partnership.

What are the chances such a group is going to open their books to you day 1, for you to verify you're supposedly making "90% of what a partner makes"?

The average ER doctor doesn't have a damn clue as to whom, to where, or what percentage of the physician fees they've generated are being paid to them, let alone a brand new baby doctor.

Do they know what percent they're collecting on what's billed?

Do they know how many of their claims are on hold or for what reasons?

Do they know how many claims are unpaid and left for dead by the billing staff?

Do they know how many of their charts are being down coded or up coded?

Do they know what percent they're paying for billing, administrative fees, bad debt?

My guess is that most have no clue and don't want to have a clue. That leaves a lot of room for the system to be gamed by those who do have a clue.

Don't assume the people writing your paycheck are compulsively watching every penny you generate to make sure it ends up in your pocket. Chances are they're doing what they can to maximize what goes in their pocket, first. I'm not saying that all is bad, or that there aren't fair deals out there. I am saying it pays to ask questions. Knowledge is power, and ignorance is dangerous.

 

[Hercules]

What are the chances such a group is going to open their books to you day 1, for you to verify you're supposedly making "90% of what a partner makes"?

The average ER doctor doesn't have a damn clue as to whom, to where, or what percentage of the physician fees they've generated are being paid to them, let alone a brand new baby doctor.

Do they know what percent they're collecting on what's billed?

Do they know how many of their claims are on hold or for what reasons?

Do they know how many claims are unpaid and left for dead by the billing staff?

Do they know how many of their charts are being down coded or up coded?

Do they know what percent they're paying for billing, administrative fees, bad debt?

My guess is that most have no clue and don't want to have a clue. That leaves a lot of room for the system to be gamed by those who do have a clue.

Don't assume the people writing your paycheck are compulsively watching every penny you generate to make sure it ends up in your pocket. Chances are they're doing what they can to maximize what goes in their pocket, first. I'm not saying that all is bad, or that there aren't fair deals out there. I am saying it pays to ask questions. Knowledge is power, and ignorance is dangerous.

I always appreciate your posts Birdstrike and your willingness to shine the light on some of the dark recesses of EM. Ultimately though your personal career experience is an n of 1, as is mine. My n of 1 has been very different, and I would describe my EM career so far as just a hair shy of Utopian. I am part of the group of posters here who are unabashedly pro SDG. The key is to have a well run SDG with some business-savvy docs in it. I'm part of just this sort of SDG with all EM trained docs and completely open books from day one. We send out the payroll spreadsheet every month so everyone can see each other's productivity, hours worked, administrative pay, overhead, and take home pay. Everyone has access to all of their billing information from day one. We have a two year partnership track where your percent of productivity gradually increases until you get 100% at the end of two years. From day one on the job you are making more per hour than the CMGs are offering in town and in the surrounding areas. As you move towards 100% the difference between us and the CMGs gets much larger. After the initial 6 month trial period you have the same vote and voice that everyone else has. We have held the contract for 30+ years since the day the hospital opened its doors. I have a supportive administration, great nursing staff, and consultants that appreciate us (it helps to have three EDs in town that are staffed by non-EM guys who do a crappy job). I say all this simply to point out that the perfect jobs that some posters on here don't believe in truly do exist. You have to do your homework but these jobs and groups are still out there. Will my job be perfect forever? I have no idea and I plan conservatively so that if it ever tanks I'll be in a position to comfortably walk away, but so far I have had a nearly perfect job.

 

[Birdstrike]

I always appreciate your posts Birdstrike and your willingness to shine the light on some of the dark recesses of EM. Ultimately though your personal career experience is an n of 1, as is mine. My n of 1 has been very different, and I would describe my EM career so far as just a hair shy of Utopian. I am part of the group of posters here who are unabashedly pro SDG. The key is to have a well run SDG with some business-savvy docs in it. I'm part of just this sort of SDG with all EM trained docs and completely open books from day one. We send out the payroll spreadsheet every month so everyone can see each other's productivity, hours worked, administrative pay, overhead, and take home pay. Everyone has access to all of their billing information from day one. We have a two year partnership track where your percent of productivity gradually increases until you get 100% at the end of two years. From day one on the job you are making more per hour than the CMGs are offering in town and in the surrounding areas. As you move towards 100% the difference between us and the CMGs gets much larger. After the initial 6 month trial period you have the same vote and voice that everyone else has. We have held the contract for 30+ years since the day the hospital opened its doors. I have a supportive administration, great nursing staff, and consultants that appreciate us (it helps to have three EDs in town that are staffed by non-EM guys who do a crappy job). I say all this simply to point out that the perfect jobs that some posters on here don't believe in truly do exist. You have to do your homework but these jobs and groups are still out there. Will my job be perfect forever? I have no idea and I plan conservatively so that if it ever tanks I'll be in a position to comfortably walk away, but so far I have had a nearly perfect job.

I'm glad you're happy with your situation. I was not referring to "all SDGs" or generalizing at all. I was referring to WC Investor's example of the "5 year to partner" type groups. Some groups are fair, some aren't. My n of 1, actually wasn't very bad. I had no clue whether it was good or not, at the time, because I had no clue about the running of the business of EM or Medicine in general. Now I know much more.

I'm not pro or con, SDG or CMG. I'm pro- "Doctor being aware of what the hell is going on regarding his own career." If you read what I wrote carefully, I even said there are fair deals out there. So you're telling me you have one. Okay. Cool.

I was specifically referring more to the groups with exorbitantly long dues-paying periods to be partner.

My point: the average 1st year EM attending has no clue of the inner workings of an SDG or CMG to know if they're getting a fair deal or not. I listed some questions to ask. Take it for what it's worth.

As far as "open books" go:

"Open books" only means something if you actually open the books. How many newbies do that?

How many newbies even know what the hell they're looking at when they're reading "the books"?

99/100 know Parkland Formula.

1/100 knows enough to open a group's books and have any clue how to use that information.

I stand by my point: That most doctors (ER or otherwise) <5 yrs post residency don't know enough to know whether they're getting a good deal or raw deal. Just tell them, "We have an 'open book' policy," and that's enough to get at least 12 months or work out of them before they start asking questions. Lots of times doc's think they are getting a bad deal, when they actually aren't. Again, it's because they know the medicine, but not a damn thing else.

 

[Groove]

Echoing the sentiment that 5 yrs to partner is...INSANE dude. You might as well stamp "sucker" on your forehead if you sign that contract. I just find it incredibly humorous to hear people paint CMGs as these blood suckers when a SDG is bleeding me half my salary or a third at best during a 2yr partnership track to fill their profit sharing coffers while beating me with the grunt-shift-schedule-fraternity-hazing-stick. No SDG in the world is going to let me see "all the numbers" prior to being there a good long time. So, I'm there a month... Are you going to let me see all the operating expenses and accounts payable/general ledger? Profit sharing distribution? Your senior partner's salaries for the past 5 years to verify that I'm being paid fairly? Are you going to show me who's profiting on the money you're making off my back during my "pre-partner" status? Are you going to risk losing a pre-partner after a few months to a year that "just didn't fit in with the group" and now has access to all your finances/operations and can pass that on to a potential competitor? If you are willing to do all that, then you shouldn't really be "open book". "Open book" these days more often than not means "Feel free to ask a few financial questions to make you feel like we're transparent, but don't ask enough to piss us off and make us feel that we're not transparent." I really hope that I'm just jaded and cynical but I have severe reservations about these mythological unicorn practice groups living on the island of Atlantis Community General.

 

[EctopicFetus]

As I recall, Ectopic's partnership track was 5 years. But I agree, that's too long. 1 year is plenty of time to know if you want to be partners with someone, both ways. Our group is two years. But if someone has such a good thing going (job, pay, location etc) that people are willing to sign on for a 5 year partnership track....hard to blame them for implementing it. It's a much bigger deal now than it used to be since SDGs are under constant threat from CMGs. But which is worse? A 5 year track where you make 90% of what a partner makes or a 2 year track where you make 40% of what a partner makes? There's more to the equation than just the length of the partnership.

Negative. 2 years to partnership. 5 years to being financially equal. My "break even" was about 3.5 years.. meaning if I took the job I did vs others offered to me after 3.5 years I would be financially whole. Truth is I got there before then.. Even better im at 5+ years.

WCI I think the question is how much money are we talking and how does this compare to another job you can find. If like my job I would be at a financial break even in 3.5 years it makes for a decent deal. Also, I researched well. My group doesnt deny partnership to people.

 

[EctopicFetus]

I always appreciate your posts Birdstrike and your willingness to shine the light on some of the dark recesses of EM. Ultimately though your personal career experience is an n of 1, as is mine. My n of 1 has been very different, and I would describe my EM career so far as just a hair shy of Utopian. I am part of the group of posters here who are unabashedly pro SDG. The key is to have a well run SDG with some business-savvy docs in it. I'm part of just this sort of SDG with all EM trained docs and completely open books from day one. We send out the payroll spreadsheet every month so everyone can see each other's productivity, hours worked, administrative pay, overhead, and take home pay. Everyone has access to all of their billing information from day one. We have a two year partnership track where your percent of productivity gradually increases until you get 100% at the end of two years. From day one on the job you are making more per hour than the CMGs are offering in town and in the surrounding areas. As you move towards 100% the difference between us and the CMGs gets much larger. After the initial 6 month trial period you have the same vote and voice that everyone else has. We have held the contract for 30+ years since the day the hospital opened its doors. I have a supportive administration, great nursing staff, and consultants that appreciate us (it helps to have three EDs in town that are staffed by non-EM guys who do a crappy job). I say all this simply to point out that the perfect jobs that some posters on here don't believe in truly do exist. You have to do your homework but these jobs and groups are still out there. Will my job be perfect forever? I have no idea and I plan conservatively so that if it ever tanks I'll be in a position to comfortably walk away, but so far I have had a nearly perfect job.

I feel similarly. I have some frustrations for sure but as one of my partners once said to me. It is hard to talk to your friends about your job cause it feels like bragging.

In the end if your SDG isnt making more than the CMG it is because it is poorly run or your contract with the hospital and/or insurers isnt up to par.

My group has owned our contract 30+ years. The hospital is happy with us. Same for our nurses and consultants. Do we have issues? Can we do it better? yes to both.

 

[EctopicFetus]

Echoing the sentiment that 5 yrs to partner is...INSANE dude. You might as well stamp "sucker" on your forehead if you sign that contract. I just find it incredibly humorous to hear people paint CMGs as these blood suckers when a SDG is bleeding me half my salary or a third at best during a 2yr partnership track to fill their profit sharing coffers while beating me with the grunt-shift-schedule-fraternity-hazing-stick. No SDG in the world is going to let me see "all the numbers" prior to being there a good long time. So, I'm there a month... Are you going to let me see all the operating expenses and accounts payable/general ledger? Profit sharing distribution? Your senior partner's salaries for the past 5 years to verify that I'm being paid fairly? Are you going to show me who's profiting on the money you're making off my back during my "pre-partner" status? Are you going to risk losing a pre-partner after a few months to a year that "just didn't fit in with the group" and now has access to all your finances/operations and can pass that on to a potential competitor? If you are willing to do all that, then you shouldn't really be "open book". "Open book" these days more often than not means "Feel free to ask a few financial questions to make you feel like we're transparent, but don't ask enough to piss us off and make us feel that we're not transparent." I really hope that I'm just jaded and cynical but I have severe reservations about these mythological unicorn practice groups living on the island of Atlantis Community General.

Our group isnt an "open book" group until you make partner. IMO this hasnt been a huge deal mostly because our hires fit into 1 of 3 categories.

1) Those who want to know but an answer of "our partners make in the top x %ile"
2) I dont care. I get to live in a great place
3) I know someone in the group and Ill get the inside info there (or I have already gotten that info from my friend)

I will say this once you make partner you can get very very detailed financials. I have been here 5+ years and I have the ins and outs of our business. I know how much payer x pays. I literally cant think of a single data point I want that I dont have. I know to the penny how much every doc in my group made last yr, and the year before and the year before etc.

There are crappy SDGs. I interviewed with them. I got offered a job by EmCare. In the end I am lucky. I strongly feel that my job put me on a financial and professional path which would be hard to duplicate.

That unicorn is out there. Do research find it. Its well worth it.

 

[Hercules]

Echoing the sentiment that 5 yrs to partner is...INSANE dude. You might as well stamp "sucker" on your forehead if you sign that contract. I just find it incredibly humorous to hear people paint CMGs as these blood suckers when a SDG is bleeding me half my salary or a third at best during a 2yr partnership track to fill their profit sharing coffers while beating me with the grunt-shift-schedule-fraternity-hazing-stick. No SDG in the world is going to let me see "all the numbers" prior to being there a good long time. So, I'm there a month... Are you going to let me see all the operating expenses and accounts payable/general ledger? Profit sharing distribution? Your senior partner's salaries for the past 5 years to verify that I'm being paid fairly? Are you going to show me who's profiting on the money you're making off my back during my "pre-partner" status? Are you going to risk losing a pre-partner after a few months to a year that "just didn't fit in with the group" and now has access to all your finances/operations and can pass that on to a potential competitor? If you are willing to do all that, then you shouldn't really be "open book". "Open book" these days more often than not means "Feel free to ask a few financial questions to make you feel like we're transparent, but don't ask enough to piss us off and make us feel that we're not transparent." I really hope that I'm just jaded and cynical but I have severe reservations about these mythological unicorn practice groups living on the island of Atlantis Community General.

Groove: Yes, 5 years is a pyramid scheme. If taking away half to a third of your salary still leaves you with more than the CMGs are offering, then are you really being bled dry? Yes, you are jaded and cynical and unfortunately didn't get the experience of being in a good SDG, but they are out there. Yes, the unicorn's horn is shimmering and beautiful. My practice is on the coast but not actually underwater. I am shooting you straight when I tell you I can answer yes to every single question you asked in your post... as of day one in our practice, but we are also very selective during the hiring process. We send out a spreadsheet every month that includes the financial details for everyone-- partner and non-partner alike. There's something to be said for honesty and transparency, and I believe good products and practices sell themselves. As a side note we are hiring for July of 2015 and July of 2016.

Bird: I am right there with you on a lot of your points and am very much pro-"Doctor awareness." Most EM docs don't want to be bothered with the business side of medicine. If a doctor doesn't want to be bothered with the financial details of medicine then they should happily prepare to be taken advantage of. As I have said in other posts, if a residency is producing EM docs who don't understand the finances of EM, then that program is hiding in an ivory tower and doing their residents a huge disservice. Producing graduates who feel they are clinically excellent should be a barebones minimum, but if that's all that has been accomplished, then the program has failed because quite frankly the clinical part of our job is the easy part. I feel very strongly on this issue. I go back to my former residency every 2-3 years and do a lecture on resident/early attending finances and how to compare job offers. I feel like that is the most useful information I can impart to residents, and I humbly entitle the lecture, "The Most Important Lecture of Your Residency." So you blog to fix the problems you see, and I lecture occasionally. Your solution is better and reaches more people, but unfortunately I don't like blogging and lack the dedication required to maintain a stout online presence like you do.

 

[gman33]

I am very appreciative of the input from my senior collegues.
Stepping into a whole new world, residents are bound to make mistakes selecting a job.
This is probably why 50% or more switch jobs in the first 2 years.

That is not a good thing for residents, and it's probably even worse for the employers.

If I luck into a great first job, these discussions will probably deserve a fair amount of the credit.

I have no problem putting in some time if the long term benefits make it good for both sides.
It just seems that a lot of the SDGs are just not going to survive in the current environment.
I would still very much like to find a SDG job, but the pre-partner deal just shouldn't be too long or at too much of a financial hit.

 

[Birdstrike]

Far and away, the single most powerful thing you can do to ensure you that you'll find the right job for you.....and number 2 and # 3 are not even close....is to,

Rent.

Do not. Do not. Do not, buy a house until you've been at a job for 12 month. I don't care how perfect you know it is. Every job is great when you're just starting. Otherwise you wouldn't be going there! Not forever, just 1 year: Rent.

 

[Birdstrike]

Bird: I am right there with you on a lot of your points and am very much pro-"Doctor awareness." Most EM docs don't want to be bothered with the business side of medicine. If a doctor doesn't want to be bothered with the financial details of medicine then they should happily prepare to be taken advantage of. As I have said in other posts, if a residency is producing EM docs who don't understand the finances of EM, then that program is hiding in an ivory tower and doing their residents a huge disservice. Producing graduates who feel they are clinically excellent should be a barebones minimum, but if that's all that has been accomplished, then the program has failed because quite frankly the clinical part of our job is the easy part. I feel very strongly on this issue. I go back to my former residency every 2-3 years and do a lecture on resident/early attending finances and how to compare job offers. I feel like that is the most useful information I can impart to residents, and I humbly entitle the lecture, "The Most Important Lecture of Your Residency." So you blog to fix the problems you see, and I lecture occasionally. Your solution is better and reaches more people, but unfortunately I don't like blogging and lack the dedication required to maintain a stout online presence like you do.

You're right. Lectures like the one you give are super important, and it's great that you volunteer do that. But none of that info is on the in-service or ABEM exam, right? And it's one lecture out of hundreds they get. So they're probably not paying as much attention as they should. When I was a resident I focused on the medicine. With as much there is to learn in 3 years I don't think any program can make a resident learn what many will have to learn in the School of Hard Knocks. I don't know how old you are, but when I was a resident, blogs and forums like this were just getting started and didn't have the gold mine of information they have now. I personally, have learned a tremendous amount form SDN, not only this forum but others as well, and other blogs. When I was training, you had to get your attendings out to a bar and buy them a few rounds of their favorite truth serum. That was not always an easy thing to do. Now you can get those same insights online, in a few minutes.

So I just put my thoughts here. I don't pretend I'm anyone of elevated importance. I use a silly pseudonym like everyone else. Some have suggested I use my real name, so my viewpoints will get more cred, or be taken more seriously.

No.

The last thing I want is to be "taken seriously." If one person reads and gets something out of it, that's enough for me. Take the words for what they are. If you find truth, take it. And if you see nonsense, or disagree I'm not going to try to pretend you need to give more value to it, because I have some title, chairmanship, or elevated position. I have none of those by the way. None. I'm just a guy, out here working, just trying to get by, that no one would know.

So I give my view, you give yours, others give theirs. Those reading can mix it all together and sort out what they think is the truth. No one's word is given greater status than any other. The reader decides. That's a beautiful thing.

One of the fatal flaws we have in this profession of Medicine, is that we give a greatly inflated weight to the words and views of people with titles, chairmanships and leadership positions. Think of how many horrendous, grave and terrible errors have been made by accepting dogma from so called "Leaders." Think of all the drugs that we were once told were good, then turned out to kill people. Think of the "Opiate do not cause addiction" mantra that every single ER doctor knew was wrong. Look at where we are now. Think of "patient satisfaction" which we know harms our patients in many cases, promotes drug abuse and harmful over testing, yet is being codified into law (HCAHPS). Think of where we are going with that:

http://archinte.jamanetwork.com/Mobile/article.aspx?articleid=1108766

So I'm not going to stand up, claim to be anyone's "leader" and tell them to let me think for them. It's just the opposite. Call me an anti-leader. What I want people to do is the exact opposite. I want people to think for themselves.