Pros and cons of joining ortho group..thoughts/comments

[Spartyon]

Hi everyone,

I'm a MSIII strongly considering PM&R and wanted to know what the pros and cons of joining an ortho group are. I know it is way early in my career to be even thinking about this but I am strongly considering this route if I enter the market in 5 years or so. I found this article from AAPMR website: http://www.aapmr.org/members/residents/newsletter/Pages/Archives/What-to-Consider-When-Joining-an-Orthopedic-Practice.aspx.

I know PMR4MSK and a few others on this forum are active members contributing and I enjoy all of their responses to threads. My knowledge of this field is mainly coming from this thread, and my pain clinic rotation and PMR rotation. I initially wanted to do anesthesia but the doom and gloom of the field is scaring me. After looking into PM&R it suited my personality more and the way I want to help patients get better from illness and injury. Some of my questions are listed below.

Are you happy you joined a multi specialty practice?

If you are the only physiatrist did you get the opportunity to become a partner or choose not to and why?

Is the market tough right now and what would it be like in five or so years based on your?

Thanks everyone for their input...this forum is full of knowledgeable contributors and I can't wait to join this profession. I believe the future of this field is bright and doors are being opened as people become aware of what their "friendly neighborhood physiatrist" can offer them.

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[Finally M3]

1) I'm happy. I have NO hospital responsibilities at all.

2) I'm the only physiatrist. I have the opportunity to become a partner. However, I'm not on a partner track at the moment; I don't think it's in my financial interest (ie my cost and overhead currently bring in more than the cost, overhead, and buy-in minus ancillary income I would receive). I'm not worried about job security for the moment, and I have a built-in backup (wife's group would hire me)

3) When I left fellowship almost 3 years ago, the job market was definitely tight. I had some leads, but my current job was the only one that came through. One of my classmates was hired on where we completed our fellowship; one went into academia down the street (GWU), one I don't know.

Hope this helps

 

[PMR 4 MSK]

Happy, but my sense of independence often butts heads with the realities of being in a group. I don't like being told what to do.

I'm not a partner. the way the group is set up, it would not make a difference with the money. Their partnership exists mainly to compensate the docs who see more unpaid pts (trauama) so the guys who get paid better can see more of the well-paying pts. They do a type of income-redistribution.

I was the first PM&R, now we have a second.

I think the market will get better for PM&R in ortho practices. They tell me at their meetings, the guys who are making the most money are utlizing PM&R to screen pre-surgical patients, take care of non-ops and do their diagnostics - EMG, nerve blocks, etc. They sp[end more time with surgical patients, and less with lower-paying non-ops.

 

[Disciple]

A couple of comments. Those in ortho groups, please comment on whether you agree or not.

1. Now that Physiatry has made in-roads into Sports Medicine, "Sports & Spine" Physiatrists will be in high demand by multisubspecialty Ortho groups (spine, sports, hip/knee, UE/hand, foot & ankle), the reason being that the group can hire fewer non-surgical physicians (lower overhead) while still covering the needs of the entire group (i.e. you can hire 1-2 Sports & Spine Physiatrists as opposed to PMR Spine+PMR/Anes Pain+Primary Care Sports Med (3-4 physicians).

2. Current initiatives/policy making by insurance carriers to have Physiatrists serve as gatekeepers for spine patients should be fully supported, and encouraged to include the full range of MSK patients, as this will offer to Physiatry, the main benefit of being part of an Ortho group, which is easy access to MSK/Spine patients, while still allowing the Physiatrist to be equal partner of, or own his or her own practice.

 

[Louisville04]

Not in an ortho group but would like to comment.

A couple of comments. Those in ortho groups, please comment on whether you agree or not.

1. ...the group can hire fewer non-surgical physicians (lower overhead) while still covering the needs of the entire group (i.e. you can hire 1-2 Sports & Spine Physiatrists as opposed to PMR Spine+PMR/Anes Pain+Primary Care Sports Med (3-4 physicians).As long as the orthopods aren't losing money, they will hire as many physiatrists and FP's as needed. If they really wanted to save money, they could hire a NP or PA and supervise them in clinic.

2....the main benefit of being part of an Ortho group, which is easy access to MSK/Spine patients, while still allowing the Physiatrist to be equal partner of, or own his or her own practice. Due to the income disparities, I think it is very difficult to be thought of as an equal partner. If you have your own practice and don't work for the ortho/neurosurgery group, you probably won't get the initial referral from the PCP for back pain either

 

[Gauss]

louisville is dead on
#1: PM&R/sports is irrelevant with ortho PA's and NP's supplanting us as nonsurgical treatment
#2: equal partner is a myth. PM&R is brought in to the group do interventions as a way to justify surgery to insurances. Then manage all the nonsurgical or FBSS cases.

 

[Disciple]

You're missing what I'm getting at.

If you're a senior partner is a multisubspecialty ortho group (spine, hip/knee, UE/hand, foot/ankle, sports) and you want to bring injections, EMGs, and maybe some stim trials, in-house, as well as bring on someone to help the sports surgeons with clinic and event coverage, do you hire a PMR/Anes pain doc + a PMR spine doc + an FP sports doc (3-4 doctors total), or do you go for lower overhead and just hire 2 PMR Sports & Spine docs who want to be really busy?

Secondly, the tradeoff in joining an ortho group is that you receive easy access to MSK/spine patients at the cost of likely never being an equal partner. Why do we need easy access to MSK/Spine patients?, because of our identity issues and poor marketing. What if you could remain independent and still receive plenty of MSK/Spine referrals? Theoretically, that is what being an insurance appointed gatekeeper for spine/MSK patients could give you. This is what is occuring to a certain extent in my area, and has resulted in a steady stream of referrals to some less than stellar Physiatrists who just so happen to be long time fixtures in particular zip codes.

 

[Spartyon]

Thanks everyone for the responses. It all makes sense from a referral standpoint. I also don't mind the fact that partnership is not realistically favorable on the physiatrists end. I'm excited for when I get into practice the msk treatments without surgery seem interesting as there are many advancements in treatment options for patients w/o surgery.

 

[specepic]

every setup has its own pros and cons. I am in an orthopedic group and it works very well. You are getting a little bit ahead of yourself, but that may not be a bad thing.

Being an orthopedic group is a great way to ensure lots of MSK ultrasound. there is also a noninterventional physiatrist who feeds me referrals of patients likely to need spine injections.

I think as healthcare is evolving, it makes sense to be in some type of a captive market. I really do not have to compete or market and I get lots of high-quality referrals.

if you are doing lots of procedures, I think you could realistically compete with orthopedics in terms of income

 

[caedmon]

louisville is dead on
#1: PM&R/sports is irrelevant with ortho PA's and NP's supplanting us as nonsurgical treatment
#2: equal partner is a myth. PM&R is brought in to the group do interventions as a way to justify surgery to insurances. Then manage all the nonsurgical or FBSS cases.

Totally disagree.

NP's and PA's often don't know what they don't know and can't handle many aspects of non-surgical treatment. A good MSK/Spine physiatrist will know and do whatever it takes to avoid sending a patient for surgery (which surgeons may sometimes not like), and therefore generate revenue while the patients that end up on the surgeon's doorstep are likely to be surgical patients.

In reference to Louisville's comment- Income disparity in and of itself is a myth. In medicine, income is based on productivity. Equality in partnership is out there, but it is probably rare to find a group that is willing to provide true equality as senior members are often more concerned about their own income than the good of the group. I am fortunate to be in a great surgical group that allows ample opportunity for physiatrists.

 

[Gauss]

You're missing what I'm getting at.

If you're a senior partner is a multisubspecialty ortho group (spine, hip/knee, UE/hand, foot/ankle, sports) and you want to bring injections, EMGs, and maybe some stim trials, in-house, as well as bring on someone to help the sports surgeons with clinic and event coverage, do you hire a PMR/Anes pain doc + a PMR spine doc + an FP sports doc (3-4 doctors total), or do you go for lower overhead and just hire 2 PMR Sports & Spine docs who want to be really busy?

You hire a PA or 2 and have them do all the injections and event coverage. all the RVU's go to you and not to another physician. ortho PA conferences are even teaching US guided injections

You guys think I'm making this stuff up???

 

[RUOkie]

It really depends upon the group. Some ortho groups are looking for someone to be "their boy". Funnel patients to the spine surgeons (one's that could be treated conservatively) to get past the insurance "gatekeeper role", and to take care of the chronic opiate patients.

Other groups are great and equitable. I worked in an academic Ortho group, and had a better relationship with the surgeons than I did with the other PM&R doc. I had an equal voice regarding contracting (since EMG's are fairly lucrative).

All things considered, though, I prefer being in solo practice.

 

[Disciple]

You hire a PA or 2 and have them do all the injections and event coverage. all the RVU's go to you and not to another physician. ortho PA conferences are even teaching US guided injections

You guys think I'm making this stuff up???

No, I don't think you're making this up, but I'm referring to the specific situation where an ortho group is looking to bring EMGs/pain procedures in-house, and maybe bring on a physician(s) to help the sports, hip/knee and UE/hand surgeons.

This is the predominant model in most non-rural settings.

 

[ghost dog]

You hire a PA or 2 and have them do all the injections and event coverage. all the RVU's go to you and not to another physician. ortho PA conferences are even teaching US guided injections

You guys think I'm making this stuff up???

WTF ?

Are these mid levels involved in the procedure decision making process here , or are they simply procedure robots ( " jimmy please do this today " ) ?

Who is teaching mid levels procedures ? Is this extending to such things as MBB ?

 

[lobelsteve]

WTF ?

Are these mid levels involved in the procedure decision making process here , or are they simply procedure robots ( " jimmy please do this today " ) ?

Who is teaching mid levels procedures ? Is this extending to such things as MBB ?

I've seen it more than once at Emory. My patients seen there by PA or NP for the surgeons and they order 3 level facet and TFESI at same time.

Injectionist does some procedure without eval of the patient.

Patient suffers.

 

[specepic]

WTF ?

Are these mid levels involved in the procedure decision making process here , or are they simply procedure robots ( " jimmy please do this today " ) ?

Who is teaching mid levels procedures ? Is this extending to such things as MBB ?

I think it was in reference to joint inj's but there certainly are groups where midlevels also do spine inj's. The PAs at my group have asked me to teach them US inj--I follow Nancy Reagan's advice. Biggest pain group in my state has an army of mid levels doing you name it (discos!).

 

[PMR 4 MSK]

WTF ?

Are these mid levels involved in the procedure decision making process here , or are they simply procedure robots ( " jimmy please do this today " ) ?

Who is teaching mid levels procedures ? Is this extending to such things as MBB ?

Sure, CRNAs can practice independently in many states, doing pain procedures. Why not NPs and PAs?

Pretty soon, we'll give the PA a PAA, and teach the PAA to do simple things like LESI and MBB, while the PA does the hard stuff like pumps and stims. Then PAA gets a CNA do to the joint injections...

 

[Gauss]

The PA already has an MA to do casting, splinting, postop wound care. He just looks at xrays and says fx aligned or not. Next!

 

[Louisville04]

I think it was in reference to joint inj's but there certainly are groups where midlevels also do spine inj's. The PAs at my group have asked me to teach them US inj--I follow Nancy Reagan's advice. Biggest pain group in my state has an army of mid levels doing you name it (discos!).

For the younger viewers out there, Nancy Reagan's advice on drugs : JUST SAY NO!

There are midlevels that do discography?

 

[RUOkie]

there is an orthopedist in my area who tells patients he is sending them to "my pain management doctor".

He sends them to his own PA.