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I was looking for a job and then I found a job and heaven knows I'm miserable now

Discussion in 'Young Ophthalmologists' started by OphthoBean, Feb 2, 2005.

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  1. OphthoBean

    OphthoBean Member

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    Yeah, I know, I should be a medicine martyr and say things like "I am not in this for the money" or "Medicine is an art and a calling...I'll subsist on beans, rice and my passion for eyes" or "Gee, I am so lucky to get paid to do what I love".

    As I am in job hunt mode with graduation nearing it is kind of depressing to go through the AAO Professional Choices listings and see that I can expect a whopping 100 -150K as a comprehensive ophthalmologist in a warm location. Maybe it would be less depressing if I wasn't hearing what my buddies in other fields were being offered. My FP pals are getting as much if not more than what I hope to get. My anesthesia bud is turning his nose up at 250K.

    And how about opening a practice? While this is possible in most primary care fields, start up costs for a well-equipped ophth office are excessively high! EM, Rads, Gas...no overhead at all. With business loan payments, office overhead, and the high cost of benefits for your employees, 70-80K in the first year out would be a GOOD thing!

    When you have a pt with loose zonules, a small pupil, and a floppy iris who is trying to sit up while you try not to phaco their oh-so-thin posterior capsule, is that stress really worth the 4-6 hundred bucks in reimbursement? Maybe if things go well it is a little worth it, but if things go bad...you could potentially get sued bigtime. "I'm blind! I'll call my lawyer at 1-800-I-SUE-BIG."

    Is it really a sin to want to vacation in Siena (it's so beautiful you know), eat jerk chicken on the white sands of a Jamaican beach, carry a Prada bag, and drive a Porsche? It probably really is a sin, thank God Lent is coming up so I can repent.

    It feels like ophthalmology seems to be a more lucrative field than it actually is unless you are a retina guy or own your own surgical center.

    Ugh.
  2. MS3NavyFS2B

    MS3NavyFS2B Member

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    This is actually good to know. Thanks for the input.
  3. f_w

    f_w 1K Member

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    > It feels like ophthalmology seems to be a more lucrative field than
    > it actually is unless you are a retina guy or own your own surgical
    > center.

    For some reason you seem to start out low in ophtho, but it picks up after that. While your FP buddies might get initial offers in the same range, their income will probably stay at that level for quite a while. In your ophtho practice, there are a couple of ways how your income will develop quite favourably after 2-3 years:

    - your surgical volume will pick up once you are established in a community for a while
    - you will make partner
    - you might be able to buy a share in an ASC and collect on a part of the technical fees

    If you are looking right now, be aware of the following phenomenon:

    -- 2-3 person group with one or two older partners is looking for a junior. The initial offered salary is somewhere on the low end with the promise of becoming partner after a year or two. They show you the numbers and it looks like the partnership income is very comfortable.
    -- A year or two passes, you are offered partnership. Yes, the numbers for the partners are still the same but: The partnership track contains a 'goodwill buy in' in addition to buy-in into AR, equipment and real estate. The older partners 'generously' offer to finance the buy-in through a note.
    -- Your senior partner announces that he will retire. Now you find out that his contract contains a buy-out provision guaranteeing him an inflation adjusted return on his outrageous buy-in from 1975 when he finally made partners after 6 years as an employee (back then, he paid a years income for 'good will'). But, to make it 'easier' for the juniors (and to save him taxes), the buy-out is spread over 5-8 years.
    -- The office sits in rented space, owned by one of the seniors. The rent seems a bit stiff, but it is a good location.
    -- Highly punitive restrictive covenant

    Lets say your employee income was XX

    Now, you look at your income and wonder what happened.

    Your partnership income XXXXXX
    - your buy-in financing X
    - your seniors buy-out XX
    - the amount you overpay for rent X
    --------------------------------------
    guess what, you still take home XX for another 5 years or so.

    These deals are abound. It doesn't look too bad initially, but after you go through the numbers, you realize that for the money you end up paying for 'buy-in' and 'senior buy-out', you could build a nice free-standing office accross the street, buy all the toys you need, buy a share in an ASC and run your own shop.

    If you think about taking one of these job/buy-in deals, make sure to have a competent attorney and accountant audit the practice before you sign anything. If a group becomes uneasy if you have your attorney look at the paperwork, something is fishy.
  4. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur Moderator Emeritus Lifetime Donor

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    Hang in there. It takes time to build a surgical practice. Starting salaries are only the tip of the iceberg.

    I do agree with you that it's difficult to find a good practice. It seems to me that people are trying to take advantage of young physicians. :(

    I also think that if you're good with your money, then you can have all that you want above. Read the "Millionaire Next Door". :D

    Good luck!
  5. ReMD

    ReMD Member

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    What are the average salaries of Ophthalmologists established in practice?
  6. Mirror Form

    Mirror Form Thyroid Storm

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    The average annual income for all ophthalmologists in '03 was about 300k.
  7. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur Moderator Emeritus Lifetime Donor

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    $225-$275K was quoted for general ophthalmologists at the Young Ophthalmologist seminar at the Academy meeting.
  8. f_w

    f_w 1K Member

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    These numbers sound allright for an average. You have to realize that there is a tremendous bandwith here. Someone in a city location in the northeast, stuck on one of these crappy buy-in deals might not even make 150k 5years into practice. At the same point in time, someone who opened shop in some small Texan town (and operates at an ASC that he bought shares in) could easily make 3 times that number.
  9. hans19

    hans19 I'm back... Moderator Emeritus

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    In.... my.... life...
    Why do I give valuble time? To people who don't care if I.... live or die?
    :(
  10. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur Moderator Emeritus Lifetime Donor

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    The grass is always greener on the otherside... anything is better than the $110-130 the Navy will pay me! ;)

    I plan on renting a house in California, and not buying.
  11. OphthoBean

    OphthoBean Member

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    Ahhhh...another Smith's fan emerges. :)

    I appreciate all the replies. I know I can hope to do better down the line. I am sitting around with a contract and just can't seem to just sign the dotted line. I am holding out for something better, but what if nothing comes. I just would love a job in sunny So Cal!
  12. mdkurt

    mdkurt Senior Member

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    Contracts are scary, but remember that nothing is forever (unless it says so in the fine print).
  13. samdo

    samdo Junior Member

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    That was a perfect description. Here is my advice to you. While you are in residency, spend as much time with private practice docs away from the university as you can. Questions like: when did you start, how did you start, where do your patients come from, what type of procedures do you perform, do you have a copy of the superbill need to be answered in your head.
    F_W is clearly experienced in private practice issues based on this one post. I couldnt have said it better myself.

    Consider a different model. Join someone, pay a part of the overhead and build your practice to synergize with the other doctors. No big salary, you make it for yourself during a time you can handle lean years. Eat what you kill after expenses. Learn the value of the dollar in expenses and complete coding/collections. Ultimately do better than a partnership tract.

    Samdo
  14. f_w

    f_w 1K Member

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    Everyone is scared to death from hanging up their own shingle. And it is a daunting task (one that I myself have shied away from so far). But consider this:

    There are a couple of office management companies out there. They essentially run your entire back-office for you, more than billing and collections. I know of one company that is pretty active in my specialty, their name is 'PerSe'. The folks I know who went with them are happy. On the surface, it doesn't come cheap, but if you consider how much they do for you it is a pretty good deal (I am not affiliated with them, I don't get kickbacks, there are other medical management companies out there).

    What you provide is :
    - office space equipment etc.
    - a corporate structure (LLC, PC)
    - yourself, your outstanding qualifications, your smile and cordial manner
    - a frontdesk girl (allways smiling, never PMSing)
    - a tech or assistant

    They provide:
    - a web-based front-desk software with insurance eligibility verification
    - help to set up your billing scale
    - negotiating with insurances/hmos
    - electronic medical record system (EMR)
    - tools in your EMR to generate the charges for their billing system
    - 'scrubbing' of your charges (to catch nasty 'code edits')
    - compliance management
    - electronic claims submission
    - bills/EOB to patients
    - payroll services and benefits administration for yourself and your employees


    So, instead of going with one of these crappy partnership tracks, consider joining a large group on a pure employee position. Maybe 50miles in the same state from a town you consider a good business location. Work for the big group for a year or two to get a feel of the PP world and a firm grasp of billing and business issues (suck as much knowledge out of the office manager as you can. The stuff you learned in residency isn't worth too much in that regard). Don't buy a BIG house, don't buy a car, pay interest only on your student loans and put some money on the side.

    After 2 years or so, you open up your own shop. For another year you will have an income comparable to residency, but once your business ramps up you will be in a far better position than your colleagues who took the 'great partnership track oppportunity' in the practice with 'old fart syndrome'. While they are paying 100k per year to their former seniors and are struggling to feed the 18 employees in a 2 MD practice (yes, I have seen that), you take home whatever you kill (-a fairly slim overhead). Downside: Forget about vacation for the first two years, you are IT 24/7.

    Also, in smaller towns, the local hospital is at times interested to get an ophtho into the hospital (or another one to kick the local guy up to speed). At times they offer help with office space and a forgivable loan for opening an office. Again, these deals are at times complex and you have to be careful that you don't end up owing some hospital 1/2 mill without much to show for it.
  15. samdo

    samdo Junior Member

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    For the services they provide, what does that company ask in return.
    Bracing myself

    Samdo
  16. f_w

    f_w 1K Member

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    Ask them.
    Personally, I am in rads which has somewhat higher billing volumes, also we have tons of little claims compared with other specialties. The number I have heard for a 5 person group was 8.5% of collections, but I don't know what 'depth' of services they purchased. (6% seems to be standard for a pure billing/collections company).
    There are plenty of other companies out there (most regional), a relative of mine runs is FP office through one of their competitors.

    The actual numbers are less important. I just want to point people towards the fact that today, you can outsource many of the business processes in a physician practice. Nobody will be able to offer you a 'practice in a box' solution, but if you are business savy, you can open your own shop with minimal capital expense.
  17. orbitsurgMD

    orbitsurgMD Senior Member

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    "Also, in smaller towns, the local hospital is at times interested to get an ophtho into the hospital (or another one to kick the local guy up to speed). At times they offer help with office space and a forgivable loan for opening an office. Again, these deals are at times complex and you have to be careful that you don't end up owing some hospital 1/2 mill without much to show for it."

    Some hospitals give great deals and some are looking for a sucker to eat their ER call which pays you nothing and doesn't really help build the paying practice you need. Ask lots of questions. Talk to the other docs in the community. Learn the existing referral patterns. Find out what the local payor mix is like. (Nothing like getting the loan package from the hospital then discovering the community actually can't support you after all, getting a loan payoff balance you either have to return in lump-sum or work off after another 2 years of post-startup community practice during which your income falls.)
  18. f_w

    f_w 1K Member

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    This was exactly the scenario I tried to allude to with the sentence:

    "Again, these deals are at times complex and you have to be careful that you don't end up owing some hospital 1/2 mill without much to show for it."

    (Example 1. A friend of mine got a 'great' offer to open an ortho office in a small town. The local community hospital offered him 450k per year guaranteed income for 2 years with a requirement to stay in town for 2 more years after that. A friendly surgical tech slipped him a note with a phone number and a name during the hospital tour. It was the prior orthopod in town who left 4 years 1 day after he started with the hospital. It turned out that it just wasn't possible to genererate sufficient collections in this town to cover a 450k take home. That guy had 2 slim years, struggling to keep afloat. The other option would have been to pay 900k+interest to the hospital to get out of the contract.
    Example 2. A relative of mine went to a small town in the south to work as a pediatrician. He initially came with the hospital deal, but after 6months he had sufficient collections to have a 'living wage' without the subsidy. At that point, he cancelled his contract with the hospital, took out a loan to pay back the 60k they had forwarded him to this point and moved into an office building accross the street. Within the next year he had a thriving practice on his own terms.)
  19. Visioncam

    Visioncam Senior Member

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    good luck, colleagues

    (original message greatly edited)
  20. jmou123

    jmou123 Junior Member

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    What kind of offers are out there for someone that completes a fellowship...Retina? Plastics? Refractive?
  21. Retinamark

    Retinamark Senior Member

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    The average first year salary for someone with a 2year retina fellowship is around 150-200. The range would be 100-250. People who sign up with a HMO make more than most in the first few years, but that salary plateaus very quickly, while those who go into a private practice will continue to grow with time.
    The biggest variable seems to be location
  22. shiro1

    shiro1 Member

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    I don't think anyone goes into medicine with money being the only goal. I just think that the stress, time dedicated to accomplishing your degree and training is a high price to pay, especially in the fields of medicine that generally have a lower compensation. But, I couldn't resist adding my story in here.

    I graduated from residency training in 2001 and married a week later. Since we had to finance our wedding we tried to make it small and skipped the honeymoon. Things were very scary because my new husband had just decided to go to medical school and we both were unemployed for a few months following graduation and student loans went into repayment! I had started a job search, but couldn't commit to a full-time job until my hubby got accepted to medical school which we would not know for another 8 months. So I tried locums... which pay well, but are hard to come by and you may need to travel far away to do them. I worked for awhile doing eye screening exams for kids in school in rural Kentucky...a very, very depressing job. Even with these measures we soon racked up almost $40,000 in credit card bills.

    Once my husband got in I went into high gear to find a job near-by. This was incredibly difficult. We had two choices, but finally I found a job which was an hour and a half drive away from the medical school. Desperate, I took it and worked there, commuting on weekends I wasn't on call, for over a year.

    Joining a private practice (the female ophthalmologist was very busy and wanted to slow down to be with her kids more) is like marrying someone. You really have to be able to work well with the other person. You need to keep in mind that it takes awhile to build up a practice as well. Usually you have a set salary for one to two years and then go to production. Some start out with a production based salary. Benefits are important to discuss as well, especially malpractice insurance and tails! Since it was a rual area the hospital offered an incentive in the form of a stipend for a set amount of years that I stayed in the area. Be sure to read the fine print though! I didn't agree to it because they wanted to charge $300,000 plus whatever amount I had received up until that moment, immediately, if I left before the specified time. Since the time was six years and I couldn't control the residency match this obviously wasn't an option for me. They kept coming back to me and telling me all things were negotiable, but never budged on the fine, so I walked away. Thank goodness that I did, because after a year I found out that my collegue really didn't want me to stay (probably because, being not-white in rural Kentucky can somewhat inhibit your practice) I wasn't building a practice. I averaged 8-10 patient visits in a day and one cataract case a week compared to 30 patients visits/5 cataracts for her.

    I started to look for another job and found several jobs that were similar in situation--people who claim they want to "slow down" or retire, but my first experience made me leery of this situation, so I found a large multi-specialty (only one other opthhalmologist) group who was looking for another ophthomologist. They offered me a first year salary that was $100,000 more than my previous year's salary and good benefits. The second year would be based upon production and by the third year I could be eligeable for share-holdership status in the physician owned practice. I took the job.

    That was 2 years ago. I am happy that I chose this job. I like the fact that I wasn't working for another ophthalmologist (with all the pressure that entails), but rather worked for a group. It still takes you awhile to build a practice, but I now see 25 patient visits daily/4 cataracts in a week. I have a professional marketing staff that helps me promote myself and a large group that continually expands by building peripheral branches in the rual OH/WV area. Now that I'm a share-holder, I'm contributing more to the overhead, but I'll be able to reap the reward of any profit and be able to sell-back my portion when I leave. We also have the advantage of a professional billing department that gets the most out of insurance. My production is dependant on my billings, not what the insurance pays me.

    Oh, and my hubby's graduating this year and plans to go into EM. We're crossing our fingers for OSU! So, we've landed on our feet, paid off the credit card debts and going gang-busters on saving towards retirement. Bottom-line, there are well-paying jobs out there if you look. You may need to go a little rural, but there are out there. My partner who is well-established general ophtho makes $325,000 and I feel like I can get there in a few years. Good luck!

    PS There are lists of salaries and benefits out there on the web. It really helps for comparing jobs. Also, get a lawyer or contract specialist to look over your contract before you sign! :love:
  23. f_w

    f_w 1K Member

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    I can't count how often I have heard the story with the senior partner 'trying to cut back' before.

    - No matter what they tell you, the senior won't send patients or even surgical cases your way. And after taking advantage of your labor for a year or two he/she decides that retiring is not in the picture for another couple of years.

    - Older female ophthalmologists are the worst slavedrivers in the business. 30 years ago you had to be tough as nails to make it in a surgical specialty, they might be friendly and motherly on the outside, but the same person will sue you over breach of contract at the drop of a hat.

    - Be very very careful with hospital retention contracts. The one they offered you sounds like a real 'pearl'. They can be a good deal (e.g. a signing bonus on a note which is forgiven on a monthly basis, if you leave before the term is up you just owe them the remainder of the principal+interest), but be sure to have a healthcare contract attorney go through it with you before you sign.

    - Key is to talk to the guy who left the job 6months before you interviewed. Don't believe a word of what the senior tells you, get the name from one of the scrub-techs in the hospital and find out the real story (or check out 1 year old copies of the local newspaper at the public library, trach him/her down using the abms and state license database). The person who left is usually happy to give you his side of the story.

    I am glad you made it. For people fresh out of residency, starting with a multispecialty group can be a good option. The money is not quite what the private guys will offer you, but you have less of a risk to be stuck with this kind of crazys. After a couple of years and understanding the business, options like buying a practice or opening your own shop become viable alternatives.
  24. ckyuen

    ckyuen Senior Member

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    I would also recommend speaking to the drug reps in the area you are looking at. They can often provide excellent leads as to who will abuse you, not share etc. In my case that's what I did, and it helped me tremendously. Be prepared to treat them like you want to be treated, befrend them and make sure they know your moving to their territory no matter what, so they know they will get business off of you. Then mention you are looking for a job.
  25. Retinamark

    Retinamark Senior Member

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    Thanks Shiro1, that is an awesome post! It is posts like that, that make this forum so interesting.
    Hopefully this Young Ophthalmologists section will soon fill up with posts like that.
  26. bk

    bk New Member

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    Long time lurker, but this thread is full of a lot of interesting info.

    Speaking of Goodwill Buy-ins, what have you recent grads paid. Despite all the talk of "goodwill is dead", it still appears to be a common part of buy-in arrangements that I'm looking at, although most are income reductions rather than straight out payments. What values have the rest of you seen to be common?

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