Joining a practice and getting partnership

[DrMDAware]

My mind is blown when my colleagues think PP is ideal and then see what the contracted rate is from insurance panels and how much a DON and HVAC costs at their ASC.

---

Members don't see this ad.

 

[drusso]

For my personality, I couldn't imagine myself working for someone else, especially at this point. I'm obsessed with doing my own labor and I enjoy risk. That's not for everyone. Some people like having a team to support them and don't want to deal with the mundane aspects of running a business. Dealing with insurance is the worst part of PP and they've pushed me to nearly quitting. I can understand how someone else would just have the hospital billing dept deal with it. Pay is good in PP but I think plenty of employed people in here make a lot more than I do. Pros and cons to both like everything else in life.

In PP, if the computer system goes down, you need to figure out what to do. Fluoro down, toilet not working, phone system down, pt complaints about billing... it can add up and the problems can be endless. It all comes down to you having to manage it. Even if you sub out the work you still have to find people you trust. That goes for all small businesses, not just a medical PP.

I value time with my wife and kids, autonomy, freedom, and however ridiculous it may sound being a farmer and manual laborer far more than money so even if I made half of hospital-employed docs I would still do PP. I couldn't have it any other way but not everyone feels that way.

@swamprat is right - anyone can start a PP if they want to. If you've come this far it's a hustle but can be done.

I'm not sure where you are in life but if you're considering PP vs employed consider writing the pros and cons down for each. Then go through them and see which direction your instinct pulls you in.

I had to unclog the toilet the other day. But I disagree: Many people don't have the tenacity, grit, attention to detail, and perseverance to make it in private practice. It's a 5 AM to 9 PM job.

 

[SC Tian]

My mind is blown when my colleagues think PP is ideal and then see what the contracted rate is from insurance panels and how much a DON and HVAC costs at their ASC.

like the way you think, we recruited an anesthesia pain guy last year, he was so happy that he will be a partner very soon, 10 months after he realized the responsibilities and risks of being a partner, decided to leave, and go back to anesthesia.

 

[Chelsea FC]

I had to unclog the toilet the other day. But I disagree: Many people don't have the tenacity, grit, attention to detail, and perseverance to make it in private practice. It's a 5 AM to 9 PM job.

you dont think most docs who went through residency who had to have tenacity, grit, attention to detail and perseverance to make it through to relay that same energy to business ?? I agree most docs are bad business people but that is because of our training not because we collectively lack the talents it takes to be successful. I would agree the exact opposite we are actually ideal group of people to be business owners but got stripped of that option by hospitals

 

[drusso]

you dont think most docs who went through residency who had to have tenacity, grit, attention to detail and perseverance to make it through to relay that same energy to business ?? I agree most docs are bad business people but that is because of our training not because we collectively lack the talents it takes to be successful. I would agree the exact opposite we are actually ideal group of people to be business owners but got stripped of that option by hospitals

I've observed that the characteristics that get selected for successful medical school matriculation are detrimental to entrepreneurial thinking and enterprise. Let's face it: The MCAT doesn't have a "creative problem-solving" section. And, as evidenced recently by ChatGPT and other "AI" models, a very narrow kind of intelligence is required to score well on both our entrance and exit exams.

Now, doctors are some of the smartest people I know. And, the hospital managers who employ them are some of the dullest people I know--mostly B- night school MBA graduates who majored in things like communications or sociology in college.

But, I've noticed that doctors get pretty overwhelmed when they get out of their niche of knowledge and skill and into the "swamp" of negotiation, leadership, conflict resolution, advocacy, and strategic thinking. In other words, all the essential skills you need to run a business. And, because those things are not exactly "rocket science," the intellectually inferior night school MBA hospital managers can master them easily and run circles around the physicians. The physicians, in response, confused by their circumstances, succumb to passive victimhood and Stockholm Syndrome. If you don't believe me, just read the next five posts after this one...

 

[BobBarker]

@drusso I agree. I also peruse the Facebook physicians community. There are a lot of physicians with peculiar personalities that would not do well in business. Low confidence, victim complexes, low EQ, disordered thinking in the majority posting topics for discussion.

 

[Agast]

@drusso I agree. I also peruse the Facebook physicians community. There are a lot of physicians with peculiar personalities that would not do well in business. Low confidence, victim complexes, low EQ, disordered thinking in the majority posting topics for discussion.

Sometimes I’m tempted to join just for the drama. Like when it’s a slow day on SDN.

 

[BobBarker]

Oh, you should definitely join. It will
make you appreciate the happy medium pain specialists live in b/w internist and surgeon.

 

[painfree23]

Lots of telemeds included in that 50 also.

What do you use telemedicine for? Do you schedule injections based on a telemedicine visit?

 

[Ducttape]

Can you take more about this? Nothing is perfect, ownership seems like trading a lot of problems of empyrean work with other problems . But overall burn out from doctors seem to be linked to lack of autonomy and pay, both of which is normally higher in ownership

i work to live, not live to work. while i spend a lot of time at work, it is not the primary focus and i do not feel i need to be here all the time i spend here.

on top of that, i am also "in it" for the science, not for the business part of this profession. i would not want business (re financial) decisions to impact decisions on treatment, which should be based on best available evidence and data.

finally, i im bad at business.



as such, PP is not suited for me.

 

[BobBarker]

It was around 50 on clinic days. One OR/ procedure room day per week. 7am to 3:00. No lunch. Telemeds on “vacation”.

What do you use telemedicine for? Do you schedule injections based on a telemedicine visit?

Refills

 

[MitchLevi]

Virtually every young doctor interviewing for their first job believes partnership involves receiving a bigger paycheck, and they have no idea what it actually means...They think partnership is a right because they completed med school, internship, residency and fellowship. Further, if the practice is several decades old with an entire board of partners it's really going to be hard to grasp the reality of the situation, which is the fact several doctors pulled 100+ hour weeks for many years. There were a lot of missed Christmases, Thanksgivings, birthdays, etc.

Tremendous risk was taken on, and the practice managed to survive insurance changes, hospital systems buying out all the referral networks, decreasing reimbursements, etc...

You don't just get to take a piece of that because you think you work hard.

Most of these doctors have never had an actual job other than being a student.

 

[Pain Applicant1]

Quick, stupid, but apropos joke:

2 friends went into business. The blue collar one was successful the Harvard MBA one was not.

Harvard MBA guy says I'm not sure what's going on. I study spread sheets, p&l statements, balance sheets, market research, pricing, segmentation, and do my demographic analysis yet my businesses keep failing. What's your secret to success?

Blue collar guy responds oh, I buy low and sell high.

I think about this often so I don't over over analyze things.

Business is really just a numbers game and one great thing about the modern age with regard to business is that you have access to real time market prices. That's really what most things come down to.

 

[Pain Applicant1]

Virtually every young doctor interviewing for their first job believes partnership involves receiving a bigger paycheck, and they have no idea what it actually means...They think partnership is a right because they completed med school, internship, residency and fellowship. Further, if the practice is several decades old with an entire board of partners it's really going to be hard to grasp the reality of the situation, which is the fact several doctors pulled 100+ hour weeks for many years. There were a lot of missed Christmases, Thanksgivings, birthdays, etc.

Tremendous risk was taken on, and the practice managed to survive insurance changes, hospital systems buying out all the referral networks, decreasing reimbursements, etc...

You don't just get to take a piece of that because you think you work hard.

Most of these doctors have never had an actual job other than being a student.

This is a pretty good summary. My pp now allows me to do the things I enjoy whenever I want. I can't imagine having to request time off to see my kids perform their ballet recital. I can pretty much do whatever I want whenever I want but it wasn't like that at the beginning. I had to put the time in and sometimes had to sleep in my office in the early days.

 

[GoBeers]

it seems that more than likely many pain docs working in a single specialty private practice won't become partner after 2 - 3 years and it doesn't seem that many people here have successfully made that transition given how many complex factors are evidently involved.

anyone care to share what compensation model they've heard moving forward as a "permanent employee?"

any of the single specialty owners here care to share what they think is a fair percentage collections model after 2 years of respectable service ?

 

[Chelsea FC]

it seems that more than likely many pain docs working in a single specialty private practice won't become partner after 2 - 3 years and it doesn't seem that many people here have successfully made that transition given how many complex factors are evidently involved.

anyone care to share what compensation model they've heard moving forward as a "permanent employee?"

any of the single specialty owners here care to share what they think is a fair percentage collections model after 2 years of respectable service ?

Quick question because im curcious. Seems you want to be associated with a smaller shop and you also interested in ownership. Have you thought about starting your own shop? As the saying goes on here, "they will never love you back". You already seem to have the interest and its a learnable skill.

 

[Agast]

There’s a relatively young pain group in my area that has a partnership model and seems fairly equitable, minus the guy who started it and doesn’t practice at all now but still collects his dues. They take their business management pretty seriously.

 

[GoBeers]

Quick question because im curcious. Seems you want to be associated with a smaller shop and you also interested in ownership. Have you thought about starting your own shop? As the saying goes on here, "they will never love you back". You already seem to have the interest and its a learnable skill.

I'd be open to any endeavor (permanent employment, multi-specialty group, single specialty group, big hospital). it's been great hearing both sides on this forum. at the end of the day, i just hope for a fair shakedown. I'm coming up on 3 years and so far so good but I don't see a long term future here (not for any particular negative reason). But the never ending discussion of "percentage collections" will come up.

west coast big city is a tough tough market to start my own. I'm in a similar position to most people here with young family, large student debt, mortgage so... to start from scratch at this point would be rough.

 

[Ferrismonk]

it seems that more than likely many pain docs working in a single specialty private practice won't become partner after 2 - 3 years and it doesn't seem that many people here have successfully made that transition given how many complex factors are evidently involved.

anyone care to share what compensation model they've heard moving forward as a "permanent employee?"

any of the single specialty owners here care to share what they think is a fair percentage collections model after 2 years of respectable service ?

Just for another data point, but this is my current setup. Work 3 years as employee, eligible for partnership afterwards with a few minor requirements. Keep in mind, in this model, "eligible" does not mean "partner". You still will have to "buy in", with lots of money, to be a partner.

 

[jsaul]

i see a lot of practices offering 50 percent of COLLECTIONS after overhead. Overhead including your salary and direct expenses

 

[cowboydoc]

Can you take more about this? Nothing is perfect, ownership seems like trading a lot of problems of empyrean work with other problems . But overall burn out from doctors seem to be linked to lack of autonomy and pay, both of which is normally higher in ownership

Autonomy is likely very closely related to job type. Pay, on the other hand, is very poorly correlated. Based on discussions here and IRL, many employed physicians make significantly more money than PP. PP is higher risk with potentially higher reward. System of pay is rigged against PP.

 

[drusso]

Autonomy is likely very closely related to job type. Pay, on the other hand, he is very poorly correlated. Based on discussions here and IRL, many employed physicians make significantly more money than PP. PP is higher risk with potentially higher reward. System of pay is rigged against PP.

It's not an accident. Elections resulted in consequences that favored some employers over other kind of employers.

 

[Ducttape]

yup.

thats why there was a 5% drop in the rate of physicians in private practice compared to employed practice. and 2020 was the first year that there were more employed physicians than private practice physicians ever.



it is also why there were 2.3 million more uninsured people from 2016 to 2019.

 

[DrSpine]

I've observed that the characteristics that get selected for successful medical school matriculation are detrimental to entrepreneurial thinking and enterprise. Let's face it: The MCAT doesn't have a "creative problem-solving" section. And, as evidenced recently by ChatGPT and other "AI" models, a very narrow kind of intelligence is required to score well on both our entrance and exit exams.

Now, doctors are some of the smartest people I know. And, the hospital managers who employ them are some of the dullest people I know--mostly B- night school MBA graduates who majored in things like communications or sociology in college.

But, I've noticed that doctors get pretty overwhelmed when they get out of their niche of knowledge and skill and into the "swamp" of negotiation, leadership, conflict resolution, advocacy, and strategic thinking. In other words, all the essential skills you need to run a business. And, because those things are not exactly "rocket science," the intellectually inferior night school MBA hospital managers can master them easily and run circles around the physicians. The physicians, in response, confused by their circumstances, succumb to passive victimhood and Stockholm Syndrome. If you don't believe me, just read the next five posts after this one...

Someone frame this. It's true, the problems start from early on. Like Elon once said, you're not being rewarded for critical thinking and creativity, you're being rewarded from Pre-Med to Residency in conformity and learning how to beat a test. Most people in medicine are not trained to think creatively outside the box, and sadly enough, though medicine SHOULD in theory warrant this type of thinking especially in pain to figure out the generator - you're largely boxed into conformity and algorithms laid out by insurances.

When a scrub like a Hospital Administrator (I know two personally and trust me, one was a total wreck in college and one failed out of his first semester of medical school then called me bragging that now he 'tells Doctors what to do' even though hes not a Doctor) runs circles around a Doctor, there's a problem. And if you realize this and demonstrate that you're not dumb and you will not fall for these tactics, you will soon be labeled like I did as a "problem" and "headache" to deal with, not being a "Team player."

 

[DrSpine]

On a sidenote, I love this topic and I am glad that everyone is giving their two cents in. I made this thread for a purpose, and it seems to be going well and you can really see the spectrum of thoughts. Let's keep it going, and I will respond to some of these replies soon.

 

[DrSpine]

@drusso I agree. I also peruse the Facebook physicians community. There are a lot of physicians with peculiar personalities that would not do well in business. Low confidence, victim complexes, low EQ, disordered thinking in the majority posting topics for discussion.

Physicians Community on Facebook is the absolute worst. I don't understand how these people are Doctors, when they find themselves to be in worst situations in the world, or often are dumb as bricks.

 

[Ronin1]

I think there are arguments for every type of practice. Having been through them from fee for service to partnership being an employee for the HOPD works best for me at this stage of my career. If I was 35 yo solo PP in an underserved area would be the plan. Right now I like the beach…

 

[drusso]

Physicians Community on Facebook is the absolute worst. I don't understand how these people are Doctors, when they find themselves to be in worst situations in the world, or often are dumb as bricks.

It's mostly because they have no life experiences.

 

[BobBarker]

Shocking amount of cultural issues related to what can be assumed are arranged marriages and adult child/parents/spouse interactions.

 

[Pain Applicant1]

One problem with solo pp is that I have no negotiating power at all - at least for the vast majority of the time. Otoh, the hospital has enormous leverage.

If I tell the insurance I'm walking unless they increase my reimbursement my guess is they'll happily bid me farewell. Not the same with a big hospital system as the payers can't afford to disrupt that many patients.

When I first started I belonged to a pho and had unbelievable rates - like $7k for a trial. Those days are long gone for me and I've been too lazy to try and find another pho.

With that said, I'm making it work and am very content with how much I'm currently generating. I think most docs are.

 

[painfree23]

Refills

Controlled substances?

 

[DrSpine]

Autonomy is likely very closely related to job type. Pay, on the other hand, is very poorly correlated. Based on discussions here and IRL, many employed physicians make significantly more money than PP. PP is higher risk with potentially higher reward. System of pay is rigged against PP.

Which is why Autonomy > Money. I tell this to people all the time. If the standard average base rate for an employee is $300k in Pain, I'd rather in theory make 250k at the end of the year but have my own autonomy than $300-350k and constantly deal with Administration / Private Equity overlord breathing down my neck with miserable work conditions.

 

[DrSpine]

Shocking amount of cultural issues related to what can be assumed are arranged marriages and adult child/parents/spouse interactions.

That's easily my favorite. 50% of the posts are, "I found out my husband is cheating on me!" My personal favorite was the Karen who was expressing her shock and outrage that her husband who recently got into bodybuilding was taking Creatine. She was concerned because "iTlL kiLl yOuR kIdNeYs."

 

[SeniorWrangler]

Virtually every young doctor interviewing for their first job believes partnership involves receiving a bigger paycheck, and they have no idea what it actually means...They think partnership is a right because they completed med school, internship, residency and fellowship. Further, if the practice is several decades old with an entire board of partners it's really going to be hard to grasp the reality of the situation, which is the fact several doctors pulled 100+ hour weeks for many years. There were a lot of missed Christmases, Thanksgivings, birthdays, etc.

Tremendous risk was taken on, and the practice managed to survive insurance changes, hospital systems buying out all the referral networks, decreasing reimbursements, etc...

You don't just get to take a piece of that because you think you work hard.

Most of these doctors have never had an actual job other than being a student.

I don’t have a dog in this fight, but I don’t think a new doc wants to pay extra for all the parenting opportunities the clinic owner missed out on.
This attitude is very common though so you should be skeptical of signing on with a practice where every other doc is 25 years older than you.

 

[Chelsea FC]

One problem with solo pp is that I have no negotiating power at all - at least for the vast majority of the time. Otoh, the hospital has enormous leverage.

If I tell the insurance I'm walking unless they increase my reimbursement my guess is they'll happily bid me farewell. Not the same with a big hospital system as the payers can't afford to disrupt that many patients.

When I first started I belonged to a pho and had unbelievable rates - like $7k for a trial. Those days are long gone for me and I've been too lazy to try and find another pho.

With that said, I'm making it work and am very content with how much I'm currently generating. I think most docs are.

How do you combat against this?

 

[Dr. Ice]

How do you combat against this?

Umm you can’t, you’re a dime a dozen, it’s a tough reality I know. People skills are very important in this game. What’s your gen? Please tell me you’re not an idealist, righteous individual who can’t take criticism well…oh wait…sorry, that might actually be an entire generation of people

 

[DrSpine]

How do you combat against this?

Aren't there virtual networks to help combat that and leverage? Like TopLine?

 

[Dr. Ice]

Aren't there virtual networks to help combat that and leverage? Like TopLine?

Combat what exactly?

 

[Dr. Ice]

Private practice =

1) “fake” large entitled ortho practice with “safety” except not..great contracts, some win some lose,
Roll the dice

2) small group, struggle for referrals, lots of marketing, seeing anything you can see, collegial, like minded

3) own shop..yeah good luck with that, hope you have generational wealth

Hospital employment =
Yes person, great contracts, clock in clock out, be prepared to spend countless hours doing online workshops for compliance literally you’re a bitch for cash..don’t get my wrong “Toby” make sure you obey your massa

“Oh don’t listen to this guy..he’s so jaded and miserable”

Except if you really think about out without the rosy blinders…I’m not

 

[Chelsea FC]

Private practice =

1) “fake” large entitled ortho practice with “safety” except not..great contracts, some win some lose,
Roll the dice

2) small group, struggle for referrals, lots of marketing, seeing anything you can see, collegial, like minded

3) own shop..yeah good luck with that, hope you have generational wealth

Hospital employment =
Yes person, great contracts, clock in clock out, be prepared to spend countless hours doing online workshops for compliance literally you’re a bitch for cash..don’t get my wrong “Toby” make sure you obey your massa

“Oh don’t listen to this guy..he’s so jaded and miserable”

Except if you really think about out without the rosy blinders…I’m not

Clearly tons of solo shop guys out there without generational wealth

 

[Chelsea FC]

Umm you can’t, you’re a dime a dozen, it’s a tough reality I know. People skills are very important in this game. What’s your gen? Please tell me you’re not an idealist, righteous individual who can’t take criticism well…oh wait…sorry, that might actually be an entire generation of people

Wait what???

 

[Dr. Ice]

Wait what???

Exactly

 

[Dr. Ice]

Clearly tons of solo shop guys out there without generational wealth

I guess, so they are paying off med school loans and taking out another loan for start up?! God bless..they know they are getting $100 for a cervical epidural right? Like maybe that much

 

[BobBarker]

Start up costs aren’t that bad. You can lease or finance everything. The real “cost” is the idle time and delay in A/R at the beginning. But you need the delay to figure things out.

 

[BobBarker]

It is $300 to $350 for a cesi in the office.

 

[DrMDAware]

Private practice =

1) “fake” large entitled ortho practice with “safety” except not..great contracts, some win some lose,
Roll the dice

Dr. Ice, could you please explain what you mean by this one? I'm having trouble understanding it. I'm tired so it might be me...

 

[Agast]

Dr. Ice, could you please explain what you mean by this one? I'm having trouble understanding it. I'm tired so it might be me...

He’s saying an ortho group sounds safe because you’re getting consistent referrals and a stronger insurance reimbursement contract, except everyone in his world is an entitled Millenial except him

 

[TIVAndy]

It is $300 to $350 for a cesi in the office.

this is NY or SF rate

 

[TIVAndy]

I am solo and was approached by a doc who wanted to join me. He basically cold called me and asked for a job. He also asked if I were to offer him a job would that include "partnership" I asked him what does "partnership mean to you"

He responding with some vague response about sharing 50/50 all the profits of the business

Then I told him what partnership meant to me. I stated that he would be responsible for running the payroll every two weeks, calculating, filing and paying state unemployment taxes every quarter, running the inventory and buying supplies, keeping up with the monthy state radiation safety requirements, paying the lease, paying the property taxes, paying the vendors , going to dr's offices to market, dealing with billing company to follow up the A/R and charges not collected from insurance companies for a myriad of reasons, paying the utilities, paying and reviewing the IT charges and IT equipment, dealing with HR and staffing issues, etc, etc ,etc

He never called me back...

ain't this the cold truth. you nailed it. with great power comes responsibility. while i make multiples of my VA physician friends, there are many days that i envy their great lifestyle. all the reasons you listed are slowly burning me out and i'm sometimes dreaming of letting it go and transition to a VA/kaiser style job (1-2 pt per hr, no management headache, great retirement benefit)

 

[powermd]

Physician Community is great, and I'm glad so many doctors are interacting with each other in a supportive and productive way in one location online. I wish we had something similar on a more local basis so the hospital guys could be in touch with the PP community. The interpersonal stories are tedious and repetitive, sure, but kind of entertaining too. I definitely get a boost hearing how many employed docs are getting F'd one way or another by their employer, and then the follow on chorus to hang a shingle. The clinical discussions are nice too- I've definitely learned a lot. If you're not a member, I would encourage checking it out.