Advice on a job offer. please

[HbA1c15]

Hello!
Can I please get some advice on a career decision/job. Also, I'm about to burst, sorry in advance. skip the rant and find the bold question at the end.

Finished residency in 2020. My residency was heavy in limb salvage, my surgical numbers in elective surgery could have been better and COVID did not help the last few months of my residency. Got a job at a PP after residency, new grad hungry to pay bills so I took whatever was open at that time thanks to COVID. Plus multiple locations pulled back their job offers due to COVID. Working in PP was horrible. horrible contract, horrible manager/boss, sketchy billing, 100k with no actual bonus structure/no benefits, independent contractor, busy clinic 25-30 patients a day. (barely paying bills and that's with thanks to COVID student loan forbearance)
-The old Pods are eating the young pods and is totally disgusting. It is real people. How the hell are we to pay any bills plus our student loans! Old pods do not understand that this is 2021! we have loans over 200k thanks to tuition increase and the cost of rent is insane. we can't afford homes. The upcoming new generations of Pods has to change this problem. We also need to do something about the stupidity process of board certification and dues. We are a laughing career. WE ARE THE PROBLEM! WE NEED TO HELP EACH OTHER AND FIGHT FOR CHANGE TO BETTER OUR CAREER, LIFE, AND MOST IMPORTANTLY PROVIDE BETTER CARE TO OUR PATIENTS.
- I love what I do in Podiatry but there are times I just wished I could have done a different career in medicine to avoid all this pod b** crap and have better respect/support from other medical docs.
- Our residencies need to change big time! we need better teachers/leaders. WE DO NOT NEED MORE SCHOOLS, WE NEED UPDATES IN ALL OUR RESIDENCIES. Ugh don't even get me started with my residency. residency was a s***show, unnecessary old Pod drama year round lol

- Cannot wait until old pods retire. I AM COUNTING ON ALL NEW PODS FOR A BETTER CHANGE. STAY ACTIVE.

*BREATHING.......*

- Anyways, I left the PP and now I have found a hospital job, that is not able to offer me a surgical position at this time.
So, currently, I need to make a decision in giving up surgery (I was told getting surgical privileges in 1-2 years is going to be hard since I have not done any surgery since leaving residency and most likely they won't be able to accommodate me w/ hospital/surgical privileges), the pay is great w/ full benefits (100k difference from previous PP job) which is great for the state and city I currently reside.

- Would you give up surgery early in your career for the only JOB available at this time. Is getting surgical privileges in 1-3 years after residency possible?
- I feel like I have my answer, as I need to pay bills and there is currently nothing else available but idk what will y'all do?

- The Job market sucks! I have searched everywhere, called many locations including all the PP in my county, walked into hospital/clinic with CV in hand {didn't get too far as COVID prohibits in person visits lol but I honestly did try), contacted hospital recruitments, made accounts for future employment announcements on hospital sites, and replied back to rep recruitments (which are super fake! sent my CV/told them what I was looking for, no response to date). At the end of the day, I understand that jobs come and go, nothing is permanent.
have a great day!

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[CaptainCool]

so 200k for a non surgical hospital job? That sounds pretty cushy but you are limiting yourself if that gets eliminated in the future

 

[Shiyuan]

Common sense IMO, take hospital job and leave the malignant PP practice. Keep contract short (1-2 years) to pay back debt and give yourself a chance to search for something else. (Having a family definitely plays a part in this decision...)

 

[AttackNME]

so you have 8 months of experience in the private practice. Did you leave already? If so, what is there to decide?

if not, then with your limb salvage background, have you been able to get privileges and do cases at local hospitals?

 

[619]

First of all, congrats on getting a better paying Job. I won't say much but if you read my previous post, I have always explained how clinic makes way more money than surgery. You can live a rich $ filled life as a podiatrist without doing surgery. There is a bunch of clinic procedures that pays more than surgery without the headache.

With your vast residency experience in limb salvage, don't even get me started on wound care weekly debridement, Collagen powder etc. Applying office skin grafts that pays thousands of dollars at each office visit weekly with no global period. Someone tell me which surgical procedure will pay you over a grand without locking you in a 3 month global. Even a simple I&D that reimburses like 200 bucks (Dispensing CAM boots pays about the same) will lock you in a 3 months global (I know about using modifiers during the global but y'all get my point). On the bright side, no more global period when you do a toe amputation.

Anyway back to your question. 100% take the damm job that pays over $200k with benefits. It is still crazy and downright embarrassing how PP hires another doctor in 2021 with no benefits, not even health insurance. It's so sad.

Also why is the hospital not offering surgery? Is it because they don't want to pay more for a "Surgeon". Look into that, it may me because if they hire you as a surgeon, then your bass pay have to be surgical in the $300k. Something to think about.

Furthermore, let's assume you have not done surgery in a while and you need to brush up on your surgery skills, you can attend a weekend cadaver course to hone up dissections skills. I know there is a Cadaver course in Atlanta done every month. Can't remember but someone here may know what course I am talking about.

I will conclude by saying take the job and fight that surgery battle privilege later. You have bills to pay and a family to feed.

I am very happy for you. Congrats buddy.

 

[air bud]

I agree. Nothing is set in stone in regards to surgery. Situations change. Your priority is more income and benefits. Would be one thing if had to incur expenses, move across country sell a house etc to obtain. If you are staying in town, nothing else changing then no brainer.

 

[JewOnThis]

Let me remind you. A DPM is a DPM. Surgery is over rated. I rather take a non surgical job for 200k with less headaches than a surgical job for 200k.

 

[Feli]

Lol. Figure out what you want to do and do it.

If you are "barely paying bills" with 100k (double mean American's income), then you probably have a manufactured crisis on your hands. Did you rack up credit cards during residency or even pod school? Why? Do you have a car payment... or worse, a lease? Why? Are you living the same standard of living (rent/groc/entertain costs) as when you are a resident so you can save or pay debt? Why not?

You can do whatever you like, but be aware your money problems won't disappear by making more $ come in the front door... you also have to correct the money flying out the back door. It is not "old pods" who do your monthly budget. Once you figure that out, do whatever you like. If you want to do surgery and everything you're trained for, do that... even if you are not very well paid. You can always learn and look for new jobs as you do. If you don't like surgery much, do office and wound care. Just be good enough to know when ppl need surgery and send them to other DPMs who do it. You should still try to get ABPM cert to leave the door cracked open to doing surgery sometime down the line... that is a good point that your fairly high paid non-op job could disappear and you'd be in a rough spot.

Personally, I'd rather do PP with some surg for $100k than $200k for non-op or $300k for nursing homes or something. It would frustrate me to no end to not be using my training and/or send ppl out for things I can easily do. That's just me.

...don't even get me started on wound care weekly debridement, Collagen powder etc. Applying office skin grafts that pays thousands of dollars at each office visit weekly with no global period...

Lol, those clever "wound masters." I love to be the one to tell their patients the wound is infected, should have had a re-vasc many moons ago, it has stalled (or is getting worse?) despite all the hocus pocus, inform them they needed diabetic shoes and custom insoles or deformity surgery years ago, and let them know $5 gauze and cleanser works as well as $100 foams and nonsense wraps. Unfortunately, by the time they get to me, they have usually had 3 different antibiotics, peanut butter and gel and every non-EBM topical and dressing maybe "graft" imaginable... and they just need an amp. I'm happy to help get them on with their life and out of the weekly debridement circus, though.

 

[DYK343]

Personally, I would open my own practice
You will struggle for awhile. It wont be easy
But the upsides are much higher than 200k a year and you can chose what you do.

 

[Shiyuan]

Sugardine them wounds, Feli.

 

[CHOPSTIX]

I think that's a great offer! You should definitely take this job. You can always brush your surgical skills with cadaver labs. To the OP, how did you go about getting this job?

 

[ldsrmdude]

Lots of good advice already. You should probably take the job.

I will just warn about skill atrophy if you’re thinking about something surgical in the future. I know a few have mentioned cadaver labs and I think they’re ok, but it would be really tough to finish a residency that didn’t give you a lot of exposure to elective surgery, work in private practice where you didn’t do any surgery, then work at a non-surgical hospital job, and think a weekend cadaver course will make you a great surgeon. The first few years post-residency are really important in making a confident and competent surgeon. I worked with an attending once during residency who admitted to me he hadn’t done any surgery in a few years. He wanted to do the case himself because he hadn’t been in the OR for a while. It was a simple case (don’t recall exactly, maybe cheilectomy or hammertoe) but it was a struggle.

Just food for thought. Like I said, I think the job offer sounds like a much better position than what you currently have and I’d probably take it if I were in your shoes.

 

[msion]

1. Take the hospital job.
2. The surgery situation may change. Surgeries don't pay that much anyway. Simple forefoot cases, plus some wound debridements and maybe I&Ds are your bread and butter. Those RVUs beat any complex rearfoot reconstruction cases. I would take a lapidus case over any flatfoot reconstruction. When I was in residency I got excited at all these complicated recon and fracture cases, now I do not even want to touch them (just think disability forms, pain meds, DMV placards, social security lawyers).
3. You were hired as an independent contractor, which means this gives you a lot of tax benefits. You can deduct quite a few expenses when you are filing your tax returns. Maybe look into this if you haven't already.

 

[heybrother]

The independent contractor game was basically a scamming/defrauding of the OP. If you're into understanding taxes and things you will at some point have sat down and tried to see if things would be better for you as an independent contractor. There are some taxes benefits like deductions and being able to match both sides (employer/employee) of a 401k which an associate in a podiatry clinic probably doesn't get. But there's big negatives too - the OP presumably had to pay both sides of social security ie. if he had been an employee he'd only have paid 6.2% to social security but as an independent contractor he paid 12.4%. In short the OP paid $6200 more in social security taxes than he would have as an employee. Oh, it gets worse. He paid both sides of Medicare too since he was independent. 2.9% instead of 1.45%. Podiatry associates working for 1 person are NOT supposed to be independent contractors. Independent contractors do things like - working when and where they please for multiple people. They don't just work in 1 office for 1 clown shoes scoundrel. In liberal states (NY/California) there are potentially government agencies that might even be interested in hearing about this because its a form of worker defrauding - the employer is trying to dump their costs onto their employees.

The heart of my paragraph above though is - IF you are asked to be an independent contractor as a podiatry associate (a) you PROBABLY should walk/find another job because you are fixing to be taken advantage of (b) You should ASK FOR WAY MORE MONEY. You can't take an independent contractor job and be paid $100K/30%. A bunch of the other expenses are going to fall on you. Also, you can essentially be fired at any time/stripped of work responsibilities since you aren't an employee.

As for being poor. I'm going to stop because it sounds like a rant but - federal income tax + 12.4% social security + 2.9% + state taxes? + trying to make a "principal touching" student loan payment ($20K+) + paying for health insurance (my family health insurance is probably $16K) + rent ($12k?) and half the OP's money is gone and he really hasn't touched a moment of daily living or touched his future tail payment or CME or ABPM testing ($1600) or ABPM dues and MOC and crap.

You should probably take the job and the money. The unfortunate truth in this profession is most people settle for something less than they should have as far as money, lifestyle, their ability etc - in your case you're settling for less "prestige" (in your mind). For the nuisance feeling that you'll refer cases to people who may not have your vision or understanding of the patient. Nothing worse than referring someone on for something and the other person just doesn't get what the problem was. That will drive you a little crazy unless you make it a point to communicate with and be on the same page as the people you refer to. You may constantly start looking for that edge - that new thing - that different thing like creating some sort of foot type orthotic system. But at least you'll be paid for it. And surgery does generate all my headaches. Did an ankle fusion the other day. Doing great - enormous sigh of relief. Did a diabetic forefoot recon - the patient got infected/feverish fever 4 days after her surgery and didn't tell me. Brought her in over the weekend to I&D her in the office. Did another diabetic forefoot recon. The hospital understaffed the OR and bumped me to 9pm at night. I went home so late I tore a piece off my eye trying to get my contact lens out and now my eye is screaming. Have a girl who needs a scope. Her mom is calling and wants to talk about it. Surgery is a wonderful thing but it sucks.

 

[deleted1097413]

$100,000 really is a poverty salary when most of us are close to $300,000 in loans. and yes that's without undergrad debt. and yes that's close to what most of us recent grads will have...

 

[HardRoadPaved]

Personally, I would open my own practice
You will struggle for awhile. It wont be easy
But the upsides are much higher than 200k a year and you can chose what you do.

I second this.

To the OP, you have the anger and the fire. The past year should be taken as a blessing in teaching what you didnt know. You can either take the cushy 200k non-surg job or take a leap of faith in yourself to open a practice. Market yourself and take over an area. Think of all the young MD/DO/NP/PA that dont know who to refer patients to. Think of all the urgent care center pop ups that want to look good when a foot case is over their head and they can call you. With the new e/m rules you can be collecting much more than you think.

Get that 200k job if you need cash flow to build up savings. Most major banks arent going to hand over cash for start-up practices. Also in all fairness by the time you credential, do real estate, set up the business you wont be functional for at least several months.

 

[Feli]

$100,000 really is a poverty salary when most of us are close to $300,000 in loans. and yes that's without undergrad debt. and yes that's close to what most of us recent grads will have...

This is simply not true.

The OP already said he is paying $0 on his loans. Even if you go with what heybrother said, $50k left after taxes (and loans... and rent!) are already paid is far better than most folks.

We have to remember that the idea of supporting a family and/or high standard of living/travel/dining/transportation/etc before you had a job is a roll of the dice. For a single person, $100k is more than fine. It's still fine for a person with sizable loans. It is fine for somebody with a stay-at-home partner. It is totally fine for a person with a financially competent partner. It will get dicey if you are trying to be the sole breadwinner and support a whole family that you started before residency was even over. Should you try for more than that? Yeah, of course, but we can't pretend $100k is bona fide poverty. If you think it is, you have too much personal debt and/or you spend too much. Until those problems are addressed, you have to hold back on the BMW lease, living in HCOL area, the trip to Europe, or the posh downtown dining and martinis. That is all.

 

[CutsWithFury]

This is simply not true.

The OP already said he is paying $0 on his loans. Even if you go with what heybrother said, $50k left after taxes (and loans... and rent!) are already paid is far better than most folks.

We have to remember that the idea of supporting a family and/or high standard of living/travel/dining/transportation/etc before you had a job is a roll of the dice. For a single person, $100k is more than fine. It's still fine for a person with sizable loans. It is fine for somebody with a stay-at-home partner. It is totally fine for a person with a financially competent partner. It will get dicey if you are trying to be the sole breadwinner and support a whole family that you started before residency was even over. Should you try for more than that? Yeah, of course, but we can't pretend $100k is bona fide poverty. If you think it is, you have too much personal debt and/or you spend too much. Until those problems are addressed, you have to hold back on the BMW lease, living in HCOL area, the trip to Europe, or the posh downtown dining and martinis. That is all.

I stopped reading your post when you said 50K was enough to live on after taxes.

Podiatry is a lucrative field. We deserve good money for the kind of work we do. Especially if you are surgically trained. I am. I literally do everything in a day. Ingrown toenails, diabetic foot care, MSK pain encounters in the morning. Then hit the OR for 2-3 elective cases. See a couple diabetic foot infection consults to end my day. Get some trauma here and there but mostly my ED cases are pus and wounds. Add all that diversity together and you got some serious money. The problem is your private practice owner is eating up all those financial gains and created some recipe in your contract to screw you out of that money.

Either get a job with ortho, an MSG or go solo. There are no other options. We as profession are worth more than 75-100K per year salary. It is really that simple. You choose to work for scummy private practice podiatrist because you are lazy and you're scared to go out on your own. This is the only way to achieve financial freedom other than fighting over the handful of ortho and MSG jobs out there. If you don't want to do solo PP then you need to pick up the phone and call every hospital in USA. Be willing to move anywhere.

I work for a hospital. Right now in my career I average 750-1000 RVUs per month. I grew the practice from nothing. There were no podiatrists on staff when I started. I had to fight with ortho to get ankle ED call and consults. I had a lot of meetings over this. I out worked the community private practice podiatrists and ate into their volume by doing every single community event I could possibly do. Sacrificing time with family on the weekends. I was willing to see any patient for any pathology in the beginning.

My volume now equates to charges of 150-200K a month that I make the hospital just from surgeries, clinic encounters and clinic procedures. These monies do not include the monies I created by ordering in house physical therapy, advanced imaging studies, labs, pathology specimens or monies I generated by consulting other specialists from my group to manage the patient.

I am the only podiatrist in my group. My semi annual bonus was 55K. The second bonus will be over 100K as this includes other bonuses that I get at the end of my year. My base salary is 280K. I got this job by just calling and applying to every hospital job in the country. I started in the beginning of my second year of residency. I even applied for orthopedic surgeon jobs because screw it I really didn't care. Someone was going to look at my CV and think maybe we should just hire a podiatrist because we don't have one on staff and the community podiatrists are lazy, don't see inpatient consults, only take commercial paying patients, only do bunions, etc etc etc. You never know what could happen.

Ortho at my hospital make double my salary. Get paid more money per RVU, do not do as many cases as I do (I am at a small hospital) and even get paid for call (I don't). They get to dump on me whenever they want and I just take it. Imagine their lives. Their total earnings are average in the ortho world due to their lack of volume. There is gross discrepancy in salaries between ortho and podiatry in the hospital employed arena. It is not right. Now look at the gross discrepancy between a hospital employed podiatrist and private practice associate. It is not right. You are getting screwed if you work for another podiatrist. The only podiatrists who make more than me are the owners who have been pimping out associates for the last 25 years making money doing nothing. Disgraceful

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Non podiatry edit: The buying power of the US dollar is going down the toilet. As we continue to print more money things will just naturally become more expensive. We are on the verge of economic crisis. Your 75-100K salary will actually be worth less in the next 5 years. Making it even harder to live while paying back your student loans and trying to enjoy your life.

What is even more sad is you don't even have any extra money to invest in other assets that are deflationary and can build wealth such as stocks, real estate, and yes even crypto currency (I hold a lot).

 

[heybrother]

The hospital vs PP game unfortunately just can't compare because of how facility fees work and the essentially vertical integration. I do an ankle fusion on a Medicare patient - practice gets $1K + x-rays postop. You do an ankle fusion the hospital gets $12K to pay for the surgery costs and $1K for you too. I get $32 per ankle x-ray. The hospital potentially gets $200-250 for the same x-rays (private insurance).

Consider the following hypothetical fake employee associate offer

-$100K base
-40% of collections for medical/surgical/procedural/imaging/whatever services
-40% of DME/"office crap" after item overhead
-Health insurance - I cover their premium 100% and allow them to pay for family coverage as needed
-401K with match
-$2500 CME per year
-Occurrence malpractice so no tail
-All hospital fees
-State licensing fees
-ABFAS/ABPM/state association yearly fees
-Web based dictation
-2 weeks PTO, the promise of liberal closure around holidays that doesn't use PTO ie. Thanksgiving, Christmas, mild illness/doctor visits/taking a morning to see your wife's ultrasound doesn't count towards PTO and we just move your patients around.
-No hospital call
-Your surgery day is for surgery - you don't have clinic afterwards

I'm reasonably confident this would be a 90-99th percentile podiatry PP offer. I've seen people be offered a $120-140K base, but I think I can still probably hire anyone with the above offer unless they have a hospital offer pending. To a hospital person though the above is just total garbage. Its wild.

 

[msuDPM]

This is simply not true.

The OP already said he is paying $0 on his loans. Even if you go with what heybrother said, $50k left after taxes (and loans... and rent!) are already paid is far better than most folks.

We have to remember that the idea of supporting a family and/or high standard of living/travel/dining/transportation/etc before you had a job is a roll of the dice. For a single person, $100k is more than fine. It's still fine for a person with sizable loans. It is fine for somebody with a stay-at-home partner. It is totally fine for a person with a financially competent partner. It will get dicey if you are trying to be the sole breadwinner and support a whole family that you started before residency was even over. Should you try for more than that? Yeah, of course, but we can't pretend $100k is bona fide poverty. If you think it is, you have too much personal debt and/or you spend too much. Until those problems are addressed, you have to hold back on the BMW lease, living in HCOL area, the trip to Europe, or the posh downtown dining and martinis. That is all.

Terrible. Terrible post. Sure, live within your means. Set goals and hit them. But with loans/cost of Ed what they are these days, the OP is in a miserable situation that is all too common. The ideal of planning on a 20-30 year repayment period for a 4 years graduate degree is SAD. You should be able to put yourself in a position to pay that off in 5-10 years. If you can't, I think 9/10 times it's a profession problem and not a person problem.

I was fortunate enough to land a job out of residency making 300++k that I hate. I own a home that costs less than 1 year of my salary. My wife also makes 6 figures. I'll pay off my loans after 4ish years. This is a dream scenario for most, including the OP and that is sad. To put the onus of the problem on the OP when he's obviously not living a kush lifestyle is a propagation of what is wrong with this profession... Not sure what I'm going to do next, but may get out in the next year, hang my own shingle with a primary goal of patient care and paying a new grad what they're worth. Pay it forward.

 

[msuDPM]

I stopped reading your post when you said 50K was enough to live on after taxes.

Podiatry is a lucrative field. We deserve good money for the kind of work we do. Especially if you are surgically trained. I am. I literally do everything in a day. Ingrown toenails, diabetic foot care, MSK pain encounters in the morning. Then hit the OR for 2-3 elective cases. See a couple diabetic foot infection consults to end my day. Get some trauma here and there but mostly my ED cases are pus and wounds. Add all that diversity together and you got some serious money. The problem is your private practice owner is eating up all those financial gains and created some recipe in your contract to screw you out of that money.

Either get a job with ortho, an MSG or go solo. There are no other options. We as profession are worth more than 75-100K per year salary. It is really that simple. You choose to work for scummy private practice podiatrist because you are lazy and you're scared to go out on your own. This is the only way to achieve financial freedom other than fighting over the handful of ortho and MSG jobs out there. If you don't want to do solo PP then you need to pick up the phone and call every hospital in USA. Be willing to move anywhere.

I work for a hospital. Right now in my career I average 750-1000 RVUs per month. I grew the practice from nothing. There were no podiatrists on staff when I started. I had to fight with ortho to get ankle ED call and consults. I had a lot of meetings over this. I out worked the community private practice podiatrists and ate into their volume by doing every single community event I could possibly do. Sacrificing time with family on the weekends. I was willing to see any patient for any pathology in the beginning.

My volume now equates to charges of 150-200K a month that I make the hospital just from surgeries, clinic encounters and clinic procedures. These monies do not include the monies I created by ordering in house physical therapy, advanced imaging studies, labs, pathology specimens or monies I generated by consulting other specialists from my group to manage the patient.

I am the only podiatrist in my group. My semi annual bonus was 55K. The second bonus will be over 100K as this includes other bonuses that I get at the end of my year. My base salary is 280K. I got this job by just calling and applying to every hospital job in the country. I started in the beginning of my second year of residency. I even applied for orthopedic surgeon jobs because screw it I really didn't care. Someone was going to look at my CV and think maybe we should just hire a podiatrist because we don't have one on staff and the community podiatrists are lazy, don't see inpatient consults, only take commercial paying patients, only do bunions, etc etc etc. You never know what could happen.

Ortho at my hospital make double my salary. Get paid more money per RVU, do not do as many cases as I do (I am at a small hospital) and even get paid for call (I don't). They get to dump on me whenever they want and I just take it. Imagine their lives. Their total earnings are average in the ortho world due to their lack of volume. There is gross discrepancy in salaries between ortho and podiatry in the hospital employed arena. It is not right. Now look at the gross discrepancy between a hospital employed podiatrist and private practice associate. It is not right. You are getting screwed if you work for another podiatrist. The only podiatrists who make more than me are the owners who have been pimping out associates for the last 25 years making money doing nothing. Disgraceful

-------

Non podiatry edit: The buying power of the US dollar is going down the toilet. As we continue to print more money things will just naturally become more expensive. We are on the verge of economic crisis. Your 75-100K salary will actually be worth less in the next 5 years. Making it even harder to live while paying back your student loans and trying to enjoy your life.

What is even more sad is you don't even have any extra money to invest in other assets that are deflationary and can build wealth such as stocks, real estate, and yes even crypto currency (I hold a lot).

Good man. We've agreed in the past. I think you're a year behind me, but in a similar position. I took over a year after a employed pod left and increased their production by 25% year one. Worked my tail off and at year 3 when my contract was up, I was ready to make demands. Was told "you have a point, but we can't do it". Cool, but im out as soon as I have everything (house, loans, nest egg) paid up and vested. Do everything from nail care to pilons, but ready to move on and maybe out of the profession. Would like to pay it forward as I go, though.

 

[msuDPM]

The hospital vs PP game unfortunately just can't compare because of how facility fees work and the essentially vertical integration. I do an ankle fusion on a Medicare patient - practice gets $1K + x-rays postop. You do an ankle fusion the hospital gets $12K to pay for the surgery costs and $1K for you too. I get $32 per ankle x-ray. The hospital potentially gets $200-250 for the same x-rays (private insurance).

Consider the following hypothetical fake employee associate offer

-$100K base
-40% of collections for medical/surgical/procedural/imaging/whatever services
-40% of DME/"office crap" after item overhead
-Health insurance - I cover their premium 100% and allow them to pay for family coverage as needed
-401K with match
-$2500 CME per year
-Occurrence malpractice so no tail
-All hospital fees
-State licensing fees
-ABFAS/ABPM/state association yearly fees
-Web based dictation
-2 weeks PTO, the promise of liberal closure around holidays that doesn't use PTO ie. Thanksgiving, Christmas, mild illness/doctor visits/taking a morning to see your wife's ultrasound doesn't count towards PTO and we just move your patients around.
-No hospital call
-Your surgery day is for surgery - you don't have clinic afterwards

I'm reasonably confident this would be a 90-99th percentile podiatry PP offer. I've seen people be offered a $120-140K base, but I think I can still probably hire anyone with the above offer unless they have a hospital offer pending. To a hospital person though the above is just total garbage. Its wild.

Agree 100%, and would add that aside from the PTO, that is a very good PP offer. I have a coresident that took a very similar deal except he has a very liberal control of his PTO. As long as he produces he can take as much time as he like. Has 2 young kids and probably works 2/3 - 3/4 time during the summer. Is busy otherwise, does primarily forefoot and routine care stuff. Makes 250-275k/year. Happy.

 

[Feli]

...We deserve good money for the kind of work we do. Especially if you are surgically trained. I am. I literally do everything...

...Either get a job with ortho, an MSG or go solo. There are no other options. We as profession are worth more than 75-100K per year salary. It is really that simple. You choose to work for scummy private practice podiatrist because you are lazy and you're scared to go out on your own. This is the only way to achieve financial freedom other than fighting over the handful of ortho and MSG jobs out there. If you don't want to do solo PP then you need to pick up the phone and call every hospital in USA. Be willing to move anywhere...

I don't necessarily disagree with anything you said, but you are comparing apples to oranges...

I can use a line or two for "CV" instead of five paragraphs: like you, I did good training, passed boards, do good surgery, know billing/coding, built a MSG podiatry dept pt and refer base from scratch (hired other pods... had multi-DPM volume when I left), now hospital employed with many other attractive options, etc.

...The OP clearly said they did a mediocre residency with not enough surgery. It is anyone's guess as to their class rank, boards, etc. They have basically zero experience. All I'm saying is that generally WON'T set you up to be competitive for most hospital/ortho/MSG jobs. The only chance would be rural or unpopular areas (and that would likely be a slim chance if OP didn't pass ABFAS or if any better trained DPM wants the job). Therefore, it is up to him/her if they want to cut their teeth at PP, learn a bit, and strive for a solo/MSG/ortho/hospital in the future. Sure, if they luck out, maybe the PP owner DPM is conscientious and can teach them a few things or they even jive well enough to become a decently paid productive associate or even partner. Either way, it is simply a bridge. They can live on 100k for awhile, if they choose to. The other option is to completely give up on surgery and board cert less than a year after residency, as they'd proposed. That is a personal call (as in my first post).

It's easy to say "no other options" when you yourself have options outside PP for ~100k base since you are well trained and/or flexible on locality, but again... apples to oranges. There are a lot more young DPMs who are low/avg trained and/or inflexible on area of practice than ones who have badass training and ability to pack up in a month or two to go to Oregon or Wisconsin - or maybe even to Montana or Maine - if the $$$ calls. Many of those mean/median young DPMs will end up in PP out of necessity after graduation. Whether they hamstrung them self with low quality training, started the job search too late or too passively, limited the job search to a narrow area, all of the above, etc is debatable. What is not debatable is that they need a job.

The clear compromise between "we deserve good money... get a job with ortho" and fiddling away in PP making 150k or less for a decade is to start in the best PP you can find (if you can't get hospital/ortho/MSG... and the vast majority cannot!). It is simply a start... a bridge. Not all PP are inherently the devil; you need to look at is from PP owner standpoint of being a relatively small business who can't risk too much on an unknown associate who may be lazy, incompetent, unlikable, green on billing, requires fairly significant (to a small biz) fees for EMR and licenses and hospitals, won't generate a dime for at least a couple months, etc. You can learn as an associate. I did. You learn billing, you can hone your communication style with patients, you can practice marketing to and building rapport with PCPs, you can live frugal, and you can keep looking for better jobs along the way if you like. Try RDPD original book... lesson 6 "Work to Learn - Don't Work for Money."
But having no job at all (and therefore no place to learn) since you turn your nose up at something that will at least pay the bills is ludicrous, though... the "no other options" just doesn't hold water.

Again, I'd be all for 2yr basic podiatry medicine residencies (office, wound care, DME, radiology, etc) and 4yr ones (all that plus inpt and surgery)... sorta like dentists. Right now, there is one clear reason we constantly have these "my life sucks, I only find mediocre PP jobs" answered with "just get an ortho/hospital job... it's easy!" That reason is training differences (and, to a lesser extent, individual differences in expectations and flexibility for jobs). That is not going to happen anytime soon, though... it is 3yrs for all DPMs now, and it is YMMV. As much as the young 3yr DPMs complain, the people who are in a truly rough spot are the 1yr and 2yr and 0yr non-cert non-surgical trained... they aren't even competitive for most of the PP associate jobs if they lose whatever their current gig is. Sure, their student loans aren't as significant, but their job switch choices are almost zero. It could always be worse. Work to learn (just try to make 500k doing that, if you're able).

The hospital vs PP game unfortunately just can't compare because of how facility fees work and the essentially vertical integration...

Pretty much, yes.^^^
The reimbursements are totally different in hospital/MSG since you have a ton of other ways for a DPM to add value that don't matter to PP in financial terms (advanced imaging, refers within hospital/MSG, labs, facility fees, etc). For PP, those only matter in the largest and well coordinated of groups. PP needs to do it on payers ($ per RVU) and volume (pts seen, procedures, surgery, DME, OTC,, etc)

Terrible. Terrible post... with loans/cost of Ed what they are these days, the OP is in a miserable situation that is all too common...

I don't think PP owners (or hospitals, or ortho groups) set podiatry tuition prices. I could be wrong on that, but I'm not.
They also don't get to decide the prices that their local payers give for RVUs.

Demonizing the job providers isn't always the best answer. Again, it could always be worse. The guys who can't quite make NFL would give anything for a few more teams in the league or a second league that paid half what NFL did... and they wouldn't blame the leagues that they got into debt in college or that their body only lasts 5-10yrs playing at that high level. Instead, they get arena or XFL or Canadian leagues or USFL or coach gig or whatever that hardly even pay a single penny on the dollar after over a decade of training hard and risking injuries.

Nothing is guaranteed. Attorneys, pharmacists, etc all have the same training and pay discrepancies that DPMs do. You have to make your own luck. Those "crummy" jobs still pay the bills, and they will teach you, light the fire to find better, and make you appreciate better if/when you get it. Those be the breaks.

[I won't reply any more in this thread... saw too many of these when I was a student/resident... sinking ship from here. Just know that you have to see both sides of the coin on this stuff. Work to learn - Don't just work for money.]

 

[king22]

With your vast residency experience in limb salvage, don't even get me started on wound care weekly debridement, Collagen powder etc. Applying office skin grafts that pays thousands of dollars at each office visit weekly with no global period. Someone tell me which surgical procedure will pay you over a grand without locking you in a 3 month global. Even a simple I&D that reimburses like 200 bucks (Dispensing CAM boots pays about the same) will lock you in a 3 months global (I know about using modifiers during the global but y'all get my point). On the bright side, no more global period when you do a toe amputation.

The Global period for a 10060/10061 (Superficial I&D) is 10 days, not 3 months.

 

[heybrother]

The Global period for a 10060/10061 (Superficial I&D) is 10 days, not 3 months.

Its still too long

 

[JewOnThis]

@Feli since when did you turn into a TFP? Lol

 

[619]

Most major banks arent going to hand over cash for start-up practices

In August/Sep 2020 in the heat of COVID and all, I got approved for a zero down $150K private business loan from Wells Fargo to open my practice. I have student loans like anyone else. The loan is 4.9% interest rate for 10 years. Very easy re-payment plan. $100 for first 3 months, then around $600 for the next 9 months and then making regular payments for the remaining term of the loan.

Going solo and opening my own practice is the best financial decision I have made. I am about 5 months into owning my practice and my monthly income (minus expenses) is twice what I was making as an associate and it is only going to go up as we go into summer and beyond. This is even in the middle of covid/lock downs. I am not even working too hard making twice as much. I am currently seeing about 6-8 patients a day, 4 days a week, few surgeries here and there and collecting (not billed) about $20K - $25K a month. My expenses (rent, payroll etc) are very low, less than $10k a month. Seeing 6-8 patients a day, I only have one staff up front, I run the back myself. I will hire an MA this summer when I am up to more than 10 patients a day. I actually had my busiest single day yesterday, saw 14 patients (a lot of same day appointments). But then I have 7 patients the following day. Still not looking to hire yet but it may happen sooner than later.

I could not have done all these if I did not work as an associate in a PP. Work to learn means to accept a crappy pay to gain experience to venture out on your own. I worked as an associate for 15 months before venturing out on my own. So for any new grad getting a job as an associate, work to learn and venture out on your own. If you fail to plan, you plan to fail. If anyone have any questions about the process, feel free to PM me.

 

[air bud]

In August/Sep 2020 in the heat of COVID and all, I got approved for a zero down $150K private business loan from Wells Fargo to open my practice. I have student loans like anyone else. The loan is 4.9% interest rate for 10 years. Very easy re-payment plan. $100 for first 3 months, then around $600 for the next 9 months and then making regular payments for the remaining term of the loan.

Going solo and opening my own practice is the best financial decision I have made. I am about 5 months into owning my practice and my monthly income (minus expenses) is twice what I was making as an associate and it is only going to go up as we go into summer and beyond. This is even in the middle of covid/lock downs. I am not even working too hard making twice as much. I am currently seeing about 6-8 patients a day, 4 days a week, few surgeries here and there and collecting (not billed) about $20K - $25K a month. My expenses (rent, payroll etc) are very low, less than $10k a month. Seeing 6-8 patients a day, I only have one staff up front, I run the back myself. I will hire an MA this summer when I am up to more than 10 patients a day. I actually had my busiest single day yesterday, saw 14 patients (a lot of same day appointments). But then I have 7 patients the following day. Still not looking to hire yet but it may happen sooner than later.

I could not have done all these if I did not work as an associate in a PP. Work to learn means to accept a crappy pay to gain experience to venture out on your own. I worked as an associate for 15 months before venturing out on my own. So for any new grad getting a job as an associate, work to learn and venture out on your own. If you fail to plan, you plan to fail. If anyone have any questions about the process, feel free to PM me.

This is the way

 

[SouthPod7]

In August/Sep 2020 in the heat of COVID and all, I got approved for a zero down $150K private business loan from Wells Fargo to open my practice. I have student loans like anyone else. The loan is 4.9% interest rate for 10 years. Very easy re-payment plan. $100 for first 3 months, then around $600 for the next 9 months and then making regular payments for the remaining term of the loan.

Going solo and opening my own practice is the best financial decision I have made. I am about 5 months into owning my practice and my monthly income (minus expenses) is twice what I was making as an associate and it is only going to go up as we go into summer and beyond. This is even in the middle of covid/lock downs. I am not even working too hard making twice as much. I am currently seeing about 6-8 patients a day, 4 days a week, few surgeries here and there and collecting (not billed) about $20K - $25K a month. My expenses (rent, payroll etc) are very low, less than $10k a month. Seeing 6-8 patients a day, I only have one staff up front, I run the back myself. I will hire an MA this summer when I am up to more than 10 patients a day. I actually had my busiest single day yesterday, saw 14 patients (a lot of same day appointments). But then I have 7 patients the following day. Still not looking to hire yet but it may happen sooner than later.

I could not have done all these if I did not work as an associate in a PP. Work to learn means to accept a crappy pay to gain experience to venture out on your own. I worked as an associate for 15 months before venturing out on my own. So for any new grad getting a job as an associate, work to learn and venture out on your own. If you fail to plan, you plan to fail. If anyone have any questions about the process, feel free to PM me.

Did your contract have a non-compete? If so, how did you work around it?

 

[dtrack22]

In August/Sep 2020 in the heat of COVID and all, I got approved for a zero down $150K private business loan from Wells Fargo to open my practice. I have student loans like anyone else. The loan is 4.9% interest rate for 10 years. Very easy re-payment plan. $100 for first 3 months, then around $600 for the next 9 months and then making regular payments for the remaining term of the loan.

The above is awesome. I wasn't able to get a loan like this during that time but judging by the credit card offers I'm starting to get again every day I'd imagine all of these lending programs are coming back if not back already. Though I haven't had the need to call Bank of America to see if their "practice solutions" program is back or not.

I was revenue neutral at month 4 which is probably a little quicker (I was anticipating it taking 6-8 months) than normal but I also had incredibly low overhead like newpodgrad which helps. At some point you do have to sink in more money than you are making in order to grow but I think that's easier to do or stomach when you are established and know you have some level of consistent revenue coming in.

 

[619]

Did your contract have a non-compete? If so, how did you work around it?

Yes I had a non-compete. I moved to the neighboring state, just outside the main metro city, 2 hours away to open my practice.

 

[HbA1c15]

I truly appreciate everyone advice and support. 💕 I started the hospital job. Going well so far.

 

[diabeticfootdr]

Try to do some surgery every year, even if only 10-20 cases. Then you can make the argument about currency in future privileging. It will keep you options open. Otherwise if you want to return to a surgical practice, it's not impossible, but you'll need to be proctored.

 

[AttendingPod]

Is the hospital a not for profit organization? If so you might be eligible for the public service loan forgiveness program. If you work for a not for profit for 10 years and do qualifying monthly payments, they will erase whatever balance is left. Not many people are aware this program is available. It must be loans through the government in order to work (if you refinanced to private sector you can’t join). This may be something to consider with the new job.

 

[air bud]

Is the hospital a not for profit organization? If so you might be eligible for the public service loan forgiveness program. If you work for a not for profit for 10 years and do qualifying monthly payments, they will erase whatever balance is left. Not many people are aware this program is available. It must be loans through the government in order to work (if you refinanced to private sector you can’t join). This may be something to consider with the new job.

I honestly wouldn't count on lasting 10 years with an employed position. Too many variables in life and also you are a podiatrist. If you were some academic at a teaching Hospital I get it. A pod? No.

 

[DYK343]

I honestly wouldn't count on lasting 10 years with an employed position. Too many variables in life and also you are a podiatrist. If you were some academic at a teaching Hospital I get it. A pod? No.

Ehh I dont know man. a lot of hospital employed DPMs are at non profits. If youre established and making them $$$ they are not going to let you go.

But I agree PSLF is risky. A lot of variables. 7 years in and the tides change. Total loss.

 

[Feli]

I honestly wouldn't count on lasting 10 years with an employed position. Too many variables in life and also you are a podiatrist. If you were some academic at a teaching Hospital I get it. A pod? No.

Yeah, I would say that goes for any position - even solo/owner.

Think just in the short to medium term. It always makes sense to browse job opportunities even if you like your job. It keeps you abreast of compensation and offerings, and you get out of that scarcity mentality by having options. Don't fall for carrots on the stick like PSLF, gotta stay here to build resume or collect cases to pass boards, or gotta get partnership down the line or buyout down the line, etc. It is one thing to have a defined and contracted buyout price for a PP when you start on with the group/solo, but hoping for that later with no defined price is foolish. Even if you have a defined buyout/partnership, you need to have compensation where it won't be a total waste of time if that falls through. With hospital or MSG or ortho employed routes, the management, the group finances overall, or co-workers, staffing, or any number of things can change... and the job can get better/worse in a hurry.

Even if you have your own solo office or a couple associated, you'd dump it to a hospital or MSG or venture cap if the price was right. You'd also potentially fold it if you hit FIRE without a buyer, payers turned terrible, strong competition came in, or if there was a rockstar opportunity elsewhere.

...this also ties into why it is fairly ill-advised to buy a house with the majority of jobs (tends to anchor you to a gig that could turn sour). It locks you into that scarcity mentality that is seldom good even if the job currently seems great, but that's an individual decision and depends a bit on one's needs and the area.

 

[JewOnThis]

Being a pod is a **** show. MDs control the hospitals, and they dictate what cases you can bring in. So yeah, no pod job will lasts forever- so start saving money for plan b.

 

[Pronation]

Being a pod is a **** show. MDs control the hospitals, and they dictate what cases you can bring in. So yeah, no pod job will lasts forever- so start saving money for plan b.

Don't worry, they will never take away the uninsured diabetic foot infections from you.

 

[JewOnThis]

Don't worry, they will never take away the uninsured diabetic foot infections from you.

True. A lot of the hospitals where I am at are starting to consult general surgeons for patients needing amputations. So remember guys, Dpm is a Dpm is a Dpm.

 

[Pronation]

True. A lot of the hospitals where I am at are starting to consult general surgeons for patients needing amputations. So remember guys, Dpm is a Dpm is a Dpm.

That's surprising. Usually they don't want to waste their time with anything other than a BKA/AKA, especially now that a toe amp is about the same RVU as a level 4 office visit...

 

[DYK343]

True. A lot of the hospitals where I am at are starting to consult general surgeons for patients needing amputations. So remember guys, Dpm is a Dpm is a Dpm.

Are you really bad at cutting off toes or something?
I dont know any general surgeons who will accept a toe amp. None.

 

[DYK343]

Yeah, I would say that goes for any position - even solo/owner.

Think just in the short to medium term. It always makes sense to browse job opportunities even if you like your job. It keeps you abreast of compensation and offerings, and you get out of that scarcity mentality by having options. Don't fall for carrots on the stick like PSLF, gotta stay here to build resume or collect cases to pass boards, or gotta get partnership down the line or buyout down the line, etc. It is one thing to have a defined and contracted buyout price for a PP when you start on with the group/solo, but hoping for that later with no defined price is foolish. Even if you have a defined buyout/partnership, you need to have compensation where it won't be a total waste of time if that falls through. With hospital or MSG or ortho employed routes, the management, the group finances overall, or co-workers, staffing, or any number of things can change... and the job can get better/worse in a hurry.

Even if you have your own solo office or a couple associated, you'd dump it to a hospital or MSG or venture cap if the price was right. You'd also potentially fold it if you hit FIRE without a buyer, payers turned terrible, strong competition came in, or if there was a rockstar opportunity elsewhere.

...this also ties into why it is fairly ill-advised to buy a house with the majority of jobs (tends to anchor you to a gig that could turn sour). It locks you into that scarcity mentality that is seldom good even if the job currently seems great, but that's an individual decision and depends a bit on one's needs and the area.

I agree. But staying until boards are done (assuming you have the case) is pretty convenient. I couldnt imagine going retrospective to try and get all the documents/records needed after leaving a practice. That would really be a pain.

 

[GreenHousePub]

Doom and gloom once again reign supreme on this forum

 

[DYK343]

Doom and gloom once again reign supreme on this forum

Yeah I dont get it. I like podiatry. Im doing pretty well financially. My hours kinda suck but my job is rewarding and im busy.

Some people will never be happy. That is true for all professions and fields.

 

[JewOnThis]

Are you really bad at cutting off toes or something?
I dont know any general surgeons who will accept a toe amp. None.

There is a very large academic hospital here. MDs are referring to their own. Also, all the wound care centers are ran by MDs.

 

[heybrother]

I've done my share of complaining. Here's my thing at the moment. Forget how bad the schools are, the residencies, the interactions, our board certification. Let's say you're just an established person in private practice seeing 20-25 a day trying to make ends meet, be surgically busy.

My tricky thing right now - insurance playing games, reducing reimbursement, denying things first pass. The feeling that you have to do more to stay in place. I do have some insurance that pays relatively handsomely for procedure. Call me a sucker but Medicare jumping E&M values by like $16 bucks on a level 3 was quite nice and I am scoring more level 4s because of the documentation change. But there's a lot of insurance that seems to be racing to the bottom. I had an enormous number of people switch from a terrible insurance to a "I thought you were good" insurance only for the 2nd insurance to cut the rates also without a word.

My office manager got something in the mail from an insurance where they were offering to pay 6 visits a year to cut nails without any qualifying traits but they will pay us dirt for it. Screw that. Incentivize people to come to me for nailcare? Pass.

I want to do right by people, do a good job, treat some MSK issues, do a bit of surgery without becoming a *****. There's way to much what I call "CASHIFICATION" - taking covered services and trying to blow them up. ie. laser, Swift, customs for everyone, etc.

I've managed to take some very positive steps for my office to improve actual service and reduce overhead, but I still find myself adding new insurance plans to my "Hate list". Humana, now United etc.

 

[air bud]

Yeah I know...I have a ton of friends just killing it. Ortho, MSG, private...doesn't matter the situation. But way more fun to complain. Also, I am switching to fulltime with ortho, don't have time for my Hospital/MSG employed job. Will still go back there 2x a month and see patients. But I just need more time aty new gig. Ortho partners super supportive, great community, doing good work and I think helping people. As always....don't work for another podiatrist.

 

[DYK343]

Yeah I know...I have a ton of friends just killing it. Ortho, MSG, private...doesn't matter the situation. But way more fun to complain. Also, I am switching to fulltime with ortho, don't have time for my Hospital/MSG employed job. Will still go back there 2x a month and see patients. But I just need more time aty new gig. Ortho partners super supportive, great community, doing good work and I think helping people. As always....don't work for another podiatrist.

My last patient today was a steel mill worker. Covered in soot. His job is to walk out over a boiling pot of molten metal and take samples. He has to suit up in multiple layers of clothes to keep the heat out. I think to myself... wow that could have been me.

 

[DYK343]

There is a very large academic hospital here. MDs are referring to their own. Also, all the wound care centers are ran by MDs.

Well joke is on them because toe amps dont pay squat anyways.
Not worth it.