Please evaluate this "Eat what you kill" job

[hckyplyr]

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Hi all,
I'm finishing residency in June 2023, still looking for a job. I've talked to a bunch of groups in SC/NC (where my wife wants to move), but haven't found strong positions yet. Many jobs offer very low non-partner salaries with the promise of the golden egg once partner. All the hospitals in my residency city has offered me positions, I'm considering the one below:
- The hospital is affiliated with my academic residency institution, so it offers the same retirement benefits, defined contribution plan, CME, which is all standard stuff, nothing too crazy
- $41 blended unit
- Do not have to work weekends if I don't want to (there are some hustlers in the group that pick up as much time as possible, so no need to work weekends).
- Some members do NOT take stand call, while others take ALOT. Again, other members will gladly take it from them. I would take the standard call, which is one 24hr shift a month, and 1 first and second call a month. Whoever is 1st call picks their room, and higher paying rooms are assigned based on higher call number. Ex. 1st call picks highest paying room, person 15 gets out first that day, but has generally lowest paying room.
- NO paid vacation, if you don't work, you don't make money. However, you're able to take up to 12 weeks (unpaid) vacation if you want
- 100% sit your own cases, no CRNAs in main ORs
- No traumas, mostly healthly ASA 1-2 pts, NO peds. No neuro besides spine. OB is fairly busy, CRNA in house overnight for OB

I'm not sure whether this is a hidden gem, or if I should run for the hills. I think it sounds great. I actually like the idea of "eat what you kill." I would know exactly how much I'm paid daily because of the blended unit. I'm directly responsible for my pay. It doesn't allow for lazy partners in a group to make money off the harder workers backs. The harder I decide to work, the more I get paid. I also like the flexibility of not having to work weekends or not take a significant amount of 24hr call. Now that I have a family and kids, q4-7 call seems much less appealing. Also, being straight out of residency, I want to sit more of my own cases before taking a job with 100% supervision. Apparently there are some issues with older attendings manipulating the schedule to take higher paying rooms (because they are on call more, and call person picks their room), despite them advertising everything is fair and equitable. Though the more I search, I'm finding that perfect "fair and equitable" group to be extremely uncommon.

Just looking for some thoughts on the position, and if this would be considered a diamond in the ruff or a horrible choice. Thank you!

 

[BLADEMDA]

You say the unit is "blended" at $41 per unit so higher paying must mean more complicated cases or quick GI room. I think room turnovers will also matter in your take home pay. I see why more members of the group take a lot of call because with this system and low blended unit one needs to really do a lot of cases to make bank.

CRNA in house for OB. So do you split that unit with the CRNA or keep the blended unit entirely for OB cases? If you keep the entire $41 per unit while the CRNA does most of the work I can see why overnight call is very easy to cover. Are there 2 attendings in house at all times? One to cover Ob and one for the OR? Is the CRNA being supervised in OB?

 

[Hoya11]

I would know exactly how much I'm paid daily because of the blended unit. I'm directly responsible for my pay. It doesn't allow for lazy partners in a group to make money off the harder workers backs. The harder I decide to work, the more I get paid.

You might be able to calculate what you made during a given day, but you have absolutely no control over that number, and can not at all predict what you will make in a given week/month/year. Meaning, you come to work, your ready to work, but its a slow day so sorry you eat that cost of your own time. You are not in control of the schedule, so you are not at all in control of your income. That unit rate is typical to low and probably reflects a large amount of CMS.

I get what you are saying about the flexibility and that is attractive. BUT you can still not take call and do 5 10hr days at 250/hr and probably make way more money without older guys in this group gaming the system and wasting your time working for only a few cases. That would be a no for me. I need to know how much I am making because I need to plan for what I can save and what I can spend.

 

[DirtDocMD]

From a lifestyle standpoint, it sounds appealing. With that said, I was with a group in 2004 that was getting $41-$42 blended per point. This wasn’t “bad” money, then, but it certainly wasn’t incredible, either. A slow month was 800 points, busy was 1100-1200. I rarely took weeks off, just the occasional 3-4 day weekend. (Just trying to point out that this group is getting no more per point than I was almost TWENTY years ago...)

Is the group deducting “expenses” (probably 6-10%) before or AFTER the $41 blended point?? Money isn’t everything, but if you’re going to take 8-12 weeks off per year, and no weekends, and very little weekday call, you could be taking home more like $38 per point, with about 800 points per month.

Do the math on that. You’re certainly not going to starve, but you’re looking at around $350k a year, when you COULD be making $500-$600k pretty easily, elsewhere, and likely STILL getting 8 plus weeks of vacation, and only occasional weekends on call.

NOT suggesting you make a decision based strictly on money, but an extra $200-$250k a year, for the first 5-10 years of your career can be significant.

Also, CAN you take more weekday calls per month, or do the “old guys” have the schedule locked up?? Postcall days off?? Think about it. If the “old guys” are taking 1-2 calls A WEEK, they are getting the benefit of a much better case selection PLUS post-call day off. I used to could get a GI or tonsil day, and whip out 75-80 points. Meanwhile, on a “normal” day, I might only get 25-30 doing 4-5 hand cases or 3 lap choles.

Point being, being “on call” may not be a bad thing, depending on how busy/taxing the NIGHTS are. You could make more being the on call guy, twice a week (two postcall days off and only work 3 days TOTAL a week), than someone else who works 5 days a week (and gets low pay schedules). Just letting you know that there are ways that guys can manipulate this...

 

[hckyplyr]

You say the unit is "blended" at $41 per unit so higher paying must mean more complicated cases or quick GI room. I think room turnovers will also matter in your take home pay. I see why more members of the group take a lot of call because with this system and low blended unit one needs to really do a lot of cases to make bank.
re 2 attendings in house at all times? One to cover Ob and one for the OR? Is the CRNA being supervised in OB?

-Yes, higher paying based on turnover, GI, ortho cases with regional, more complicated cases, etc.
- One attending in house overnight, CRNA places epidurals, CRNA salaried by hospital and MD takes the epidural reimbursement

You might be able to calculate what you made during a given day, but you have absolutely no control over that number, and can not at all predict what you will make in a given week/month/year. Meaning, you come to work, your ready to work, but its a slow day so sorry you eat that cost of your own time. You are not in control of the schedule, so you are not at all in control of your income. That unit rate is typical to low and probably reflects a large amount of CMS.

I get what you are saying about the flexibility and that is attractive. BUT you can still not take call and do 5 10hr days at 250/hr and probably make way more money without older guys in this group gaming the system and wasting your time working for only a few cases. That would be a no for me. I need to know how much I am making because I need to plan for what I can save and what I can spend.

Correct, they have "projections" of what you will make. Everyone makes $500k+ from all the numbers they've shown me, but I understand there is no specific guarantee. I think the blended unit is subsidized by the university, so patient insurance makes no difference. I'm assuming you're talking about locum for $250/hr? I'm not open to the travel/unpredictability/short term nature of that especially with family and kids.

Thank you both for your comments

 

[Guillemot]

Low blended unit value. I would pass on it unless there is some other type of remuneration like call stipends or fully paid benefits.

 

[DirtDocMD]

Low blended unit value. I would pass on it unless there is some other type of remuneration like call stipends or fully paid benefits.

My guess is, some of the “old guys” are taking advantage of the “call guy picks schedule” deal, and the “call guy gets epidural money from CRNA-placed epidurals”. I could be wrong, but asking some of the “lifestyle” guys about their pay (someone who is taking 8-10 weeks plus vacation and no weekend calls AND only one weekday a month), could quickly clear things up.

Remember also that one person’s 30 point day might finish up at 11am. Another’s might involve making 20 points from 8-11, THEN waiting around til 2:30 to start a 2 hour hand case (goes til 430pm).

“Eat what you kill” sounds great, until you realize that waiting for surgeons to arrive pays ZERO under that system...

 

[BLADEMDA]

$41 per unit minus billing costs means the hospital isn't paying much of a stipend at all. I would guess that the "stipend" consists of the CRNA's salary for OB coverage. Also, the CRNA is essentially independent at night if the attending is doing his/her own cases while the CRNA covers OB.

In this job market with everyone hiring you could do so much better with a 2 year partnership track starting at $300K. If you can find something better in your area then I recommend you pass on this job.

 

[Lashler9054]

I work in an “eat what you kill” practice and I prefer it over salary. I can tolerate being on unpaid vacation. I don’t like feeling of getting screwed which is what I would feel if I felt like I was putting in more hours in a salary situation.

However, the structure of your practice just means that starting off, you’re getting paid less than what you’re generating with the difference probably going to the partners. There’s no guarantee you’ll want to stay or that they will want you as partner. That’s not a risk I’d take but that’s just me.

I work in PP so it may be different than opportunity you present. I don’t have as much flexibility as you think. If you’re short staffed like my practice is, you end up taking more call anyways. I also can only guarantee I’ll be done by 5 (not before) on non call days. If you get paid at blended rate, you are less expensive than a Locums getting paid a high hourly rate. If your hospital is busy, there’s more incentive to let Locums go home before you.

Also, how are numbers 3-15 assigned on any day? Perhaps this is how older partners game the system

 

[ranvier]

This sounds a lot like my first group. Forget projections, when I was interviewing and was interested in a candidate, I would show the wheel/schedule and my deposit history.

You are correct that truly fair and equitable is hard to find. But also consider the perspective of the guy who has cultivated surgeons to use the group versus a brand new grad joining up. Or Joe Senior seems to get more Friday first calls in year which tends to be the best day because of that Friday Endo lineup.

This type of group usually runs a little lean as you don’t want people wanting to work sitting home. Try to speak with a couple members that have been there 1-2 years for the real scoop. Imo eat what you kill performing your own cases can be the best structure if personalities are like minded. Good luck.

 

[ToKingdomCome]

Is private practice really the move? What’s a good academic pay that makes it respectable to stay there as opposed to PP?

 

[IMGASMD]

Some of the cons reminded me of a group that will only hire “mommy track” people at first. Then you can only take Friday/Saturday calls. Week day calls are only for partners….

One of my attending told me something that I will always remember. Sometimes the problem isn’t working too much, it’s when there isn’t the opportunities to earn….

If you truly have access to equal schedule, then great; or it may be easier/more stable to find a parent track place and call it a day.

I do like the fact that it’s 100% own case, at least in OR. How many deliveries a year, do you know?

Good luck.

 

[dabears505]

Joining an eat what you kill practice is similar to being an eager cheetah in the Serengeti. You are excited to hunt and kill, but always have to be aware of the lions and hyenas that may rip you to shreads.

 

[Turtlez]

$41 per unit minus billing costs means the hospital isn't paying much of a stipend at all. I would guess that the "stipend" consists of the CRNA's salary for OB coverage. Also, the CRNA is essentially independent at night if the attending is doing his/her own cases while the CRNA covers OB.

In this job market with everyone hiring you could do so much better with a 2 year partnership track starting at $300K. If you can find something better in your area then I recommend you pass on this job.

What is a good blended value in your opinion? What about post-stipend blended value?

 

[nimbus]

I work in an “eat what you kill” practice and I prefer it over salary. I can tolerate being on unpaid vacation. I don’t like feeling of getting screwed which is what I would feel if I felt like I was putting in more hours in a salary situation.

However, the structure of your practice just means that starting off, you’re getting paid less than what you’re generating with the difference probably going to the partners. There’s no guarantee you’ll want to stay or that they will want you as partner. That’s not a risk I’d take but that’s just me.

I work in PP so it may be different than opportunity you present. I don’t have as much flexibility as you think. If you’re short staffed like my practice is, you end up taking more call anyways. I also can only guarantee I’ll be done by 5 (not before) on non call days. If you get paid at blended rate, you are less expensive than a Locums getting paid a high hourly rate. If your hospital is busy, there’s more incentive to let Locums go home before you.

Also, how are numbers 3-15 assigned on any day? Perhaps this is how older partners game the system

Best to go down the list in the evening and have everybody pick their own lineups for the following day. That’s how we do it.