Am I crazy?

[MalibuPreMD]

Been a member of SDN since Freshman year of college in 2006. It's been a while but I have always appreciated the advice.

My training has always been in large cities at major academic hospitals. Towards the end of fellowship I felt like less of a doctor and more of a technician than I felt even as a junior resident: Most days I was doing between 3-5 cases, 8-10 calls per month, 30-50 patients on my list(s), not enough time to get to know my patients, care for my complications. The pay sucked, the camaraderie sucked, god bless the residents and NPs who were fantastic. I found at the end of ACS fellowship that I was completely burned out, cynical against health systems, and as I was looking for jobs it was just more of the same everywhere I looked. I have kids and I just felt like I was going to be an indentured servant to whatever system I signed on with, with no real flexibility to dictate my time for my kids, nor the ability to bill for the services that I provided.

I was gung-ho academics/research entering fellowship but there was so little time and support for research as a fellow that my productivity has fallen off and I'm not in any place to apply for grants or negotiate protected time. I didn't sign on for an academic job and am now working per diem (same big hospital chain, not making great money, clearly no career trajectory from this position) but the week on week off schedule is helping me to feel normal after many years of not feeling normal (granted I've only been done with training for 6 weeks). I will say It felt great getting to take my kids to their first day of school.

I have a job opportunity that I am strongly considering and would love the sage advice of those more seasoned (sorry doctors in training, I don't want your 2 cents). I have a rural job opportunity, not academic, in paradise. A mostly poor population but there are a lot of tourists that come through needing EGS services. The trauma is great, I'll get a reasonable stipend for taking call (1 week on 24/7 q4 weeks). They need an intensivist (5 bed ICU, low acuity mostly medicine pts, would split with the other intensivist staffing 2 weeks on 2 weeks off; the hospitalist/nocturist would do consults/admissions/nursing issues for most overnight issues) and I would otherwise set up a private practice general surgery gig covering broad spectrum general surgery and basic vascular (a lot of diabetes so wounds and dialysis access will be a big part of my practice). The other surgeons at the hospital are fabulous and even though each works as an independent private practitioner the camaraderie is excellent. There is even a small surgery center that I will be able to do smaller cases at (lap hernias, lumps and bumps, etc).

The setup: Private practice LLC. Private billing for all cases, consults, procedures, ICU work. Medicaid pays medicare rates. The major insurer for the community pays 3x medicare. All docs in the community have signed on to a PPO so I don't have to negotiate contracts with insurance. About 1/3rd of the community is uninsured. Outpatient will use Charm EMR (cheap) inpatient Meditech (ugh), 3rd party biller, one of the surgeons will sublease clinic space to me 1-2x/week. The hospital will supply the wound care center and I'll have a WOC RN twice a week (working on her APRN but will be 2 years before she can functioning independently).

The pros: The hours will be much better. I will have flexibility. I will live in a beautiful location. I really like the community feel of the hospital. Very underserved patient population and there is a lot of medical need. I'll feel like a doctor again. The private school for my kids is fabulous.

The cons: I have only ever lived in cities and trained at major academic institutions. WTF do I know about rural living, building a practice, billing. There is a not insignificant chance that I move my family down and fail (I have no support whatsoever). I guess then I come back and find a job as an ACS surgeon somewhere? Hard on the kiddos (and my wife) to move so much. How much of my care is not going to be reimbursed? What is the transition like going from a hospital with every resource (sub specialist consult services, ECMO, Da Vinci's, IR... the basic academic stuff) to a place that has very little to none of these.

Should I take the risk? 99% of me says yes. What do you all think?

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[cpants]

Been a member of SDN since Freshman year of college in 2006. It's been a while but I have always appreciated the advice.

My training has always been in large cities at major academic hospitals. Towards the end of fellowship I felt like less of a doctor and more of a technician than I felt even as a junior resident: Most days I was doing between 3-5 cases, 8-10 calls per month, 30-50 patients on my list(s), not enough time to get to know my patients, care for my complications. The pay sucked, the camaraderie sucked, god bless the residents and NPs who were fantastic. I found at the end of ACS fellowship that I was completely burned out, cynical against health systems, and as I was looking for jobs it was just more of the same everywhere I looked. I have kids and I just felt like I was going to be an indentured servant to whatever system I signed on with, with no real flexibility to dictate my time for my kids, nor the ability to bill for the services that I provided.

I was gung-ho academics/research entering fellowship but there was so little time and support for research as a fellow that my productivity has fallen off and I'm not in any place to apply for grants or negotiate protected time. I didn't sign on for an academic job and am now working per diem (same big hospital chain, not making great money, clearly no career trajectory from this position) but the week on week off schedule is helping me to feel normal after many years of not feeling normal (granted I've only been done with training for 6 weeks). I will say It felt great getting to take my kids to their first day of school.

I have a job opportunity that I am strongly considering and would love the sage advice of those more seasoned (sorry doctors in training, I don't want your 2 cents). I have a rural job opportunity, not academic, in paradise. A mostly poor population but there are a lot of tourists that come through needing EGS services. The trauma is great, I'll get a reasonable stipend for taking call (1 week on 24/7 q4 weeks). They need an intensivist (5 bed ICU, low acuity mostly medicine pts, would split with the other intensivist staffing 2 weeks on 2 weeks off; the hospitalist/nocturist would do consults/admissions/nursing issues for most overnight issues) and I would otherwise set up a private practice general surgery gig covering broad spectrum general surgery and basic vascular (a lot of diabetes so wounds and dialysis access will be a big part of my practice). The other surgeons at the hospital are fabulous and even though each works as an independent private practitioner the camaraderie is excellent. There is even a small surgery center that I will be able to do smaller cases at (lap hernias, lumps and bumps, etc).

The setup: Private practice LLC. Private billing for all cases, consults, procedures, ICU work. Medicaid pays medicare rates. The major insurer for the community pays 3x medicare. All docs in the community have signed on to a PPO so I don't have to negotiate contracts with insurance. About 1/3rd of the community is uninsured. Outpatient will use Charm EMR (cheap) inpatient Meditech (ugh), 3rd party biller, one of the surgeons will sublease clinic space to me 1-2x/week. The hospital will supply the wound care center and I'll have a WOC RN twice a week (working on her APRN but will be 2 years before she can functioning independently).

The pros: The hours will be much better. I will have flexibility. I will live in a beautiful location. I really like the community feel of the hospital. Very underserved patient population and there is a lot of medical need. I'll feel like a doctor again. The private school for my kids is fabulous.

The cons: I have only ever lived in cities and trained at major academic institutions. WTF do I know about rural living, building a practice, billing. There is a not insignificant chance that I move my family down and fail (I have no support whatsoever). I guess then I come back and find a job as an ACS surgeon somewhere? Hard on the kiddos (and my wife) to move so much. How much of my care is not going to be reimbursed? What is the transition like going from a hospital with every resource (sub specialist consult services, ECMO, Da Vinci's, IR... the basic academic stuff) to a place that has very little to none of these.

Should I take the risk? 99% of me says yes. What do you all think?

Couple of things jump out to me. First, it sounds like you love the location and work, so I would lean toward going for it from that standpoint. I think you are right to have concerns about other factors though.

Usually moving to a very rural/underserved location should mean you are paid MORE than someone in a city or popular suburb with equivalent training/job description. Working as an employee of the rural hospital, that is simple -- they just pay you more, and right from the start. Starting from scratch in PP in an area where 1/3 of the people are uninsured, I have concerns. What percentage of the paying patients are Medicare/Medicaid vs the private insurer paying 3x medicare?

You are basically starting a new business here, so I would treat it like that. Need a business plan that makes sense with best estimates you can for gross revenue and overhead with the net being how much you are making. Would spend a lot of time talking to the other general surgeons there about how they are set up, how much they are making, payor mix, call coverage, overhead costs (employees, insurances, rent) etc., etc. Is there any opportunity for a partnership or hospital-employed situation in this location? Something like that could have financial and other advantages while the workday looks pretty similar. So if those are options, you should definitely look at it and compare to setting up on your own.

Understanding you want to be in PP, I also might try to talk with the hospital about some kind of service agreement with them so that you can get some compensation for all the uninsured patients you will be operating upon and caring for in the ICU. I am not an expert on this type of thing, but maybe someone who is can weigh in.

It sounds like you are pretty burnt out at this point, but I would be careful about idealizing this opportunity in your mind from work/life balance standpoint. Rural GS starting out as a solo PP covering the ICU 2 weeks a month sounds to me like it will be VERY hour intensive.

Finally, if you are going down this road, make sure you save a big nest egg to get you started down there. You will have business and personal expenses, and in a new solo PP you are going to start out making close to nothing until you ramp up volume and some reimbursements start coming in.

 

[MalibuPreMD]

Thanks for the reply.

Working on the nest egg but there sure is a lot of debt to pay off... The plan is to keep the per diem job at least through the end of 2024.

"Understanding you want to be in PP, I also might try to talk with the hospital about some kind of service agreement with them so that you can get some compensation for all the uninsured patients you will be operating upon and caring for in the ICU. I am not an expert on this type of thing, but maybe someone who is can weigh in."
I would greatly value any input on how to negotiate this with the hospital.

Two of the three general surgeons are mid career and are doing very well with their practices. The third is a few years out of training and I believe is doing well.

I don't believe there is a partnership option and there is no setup for full time hospital staff appointment - though I would be paid a stipend for the call that I take that is ~25-50th percentile of urban per diem jobs here in the Northeast. As I noted before, I would be able to bill for all of the patient care provided while on call. As long as the patients are insured that should work out great...

For the PP setup I would be a "micropractice" with no employees aside from a virtual assistant (Edge: Global Hiring Made Easy | Find Your Next Hire with Edge) for booking, preauthorization, and clinic note writing. Sublease would be reasonable rate - especially compared to what it would cost to lease or sublease in a major city. Charm EHR is only $200/month. All of this to say I would try to keep things as simple as possible and really minimize overhead.

The ICU is open and most of the work is currently carried out by the hospitalist during the day and nocturist at night. I would function mostly as a consultant (which is an odd setup I think but the other intensivist couldn't be the only one in the unit all the time so that's how they set it up).

 

[eyeeye_captain]

First, is your wife on board? I mean really on board. If you’re burning out, odds are your partner is to an extent as well (been there). There are always other jobs if this one doesn’t work for her. If you’re already at 99%, I would think this might be the only real hang up for you. That said, here are some questions and comments.

How rural are we talking? Everybody has a different definition. Sometimes it’s best to look at the population needed to support a doctor in a particular specialty. Mine needs about 100k per doc, the ACS says their ideal is 13k for a general surgeon but the national average is around 18k. For 4 surgeons in the community, split the difference and say you guys probably need 60k.

Great trauma with a 5 bed mostly medical ICU doesn’t seem to fit, but I don’t do ACS, so what do I know. Maybe I just worked too many Level 1s.

If you’re already at 1/3 uninsured, I bet there’s a strong Medicaid presence as well, probably pushing well over 50% combined. The other docs may be collegial, but you’re not their partner, and you getting referrals potentially loses them money. They’re also established in the community already, so the referral sources are more likely to send them the good insurance for a while. The private practice side will be nonexistent to slow for a while so start networking. It’s pretty much impossible to build a strong practice via the ED only.

Maybe you can get the hospital to pay you Medicaid rates on the uninsured so you’re more likely to get paid, but I suspect they’ll claim that’s factored into the (strangely low for “rural”) call pay and any base you’re getting for the ICU. They’d have to do it for the other guys too. They’re already probably writing a lot of that billing off, so you’re just another drop in the bucket. Shoot your shot. You have more bargaining leverage if the other surgeons want protection too (spoiler: they do if they don’t already have it).

Do you get a salary for the ICU? No salary, no dough if you’re not documenting a consult on the patients the IM folks have already done the critical care note for. The hospital is flirting with an audit if the model is to have you drop a consult on every patient so you get paid.

I like that you’re planning on running lean, especially if you may be fighting up to 18 years of compounding loan interest. Try to budget with only the call and ICU pay in the plus category, nothing from possible procedures. Assume the worst case so you don’t get caught with your pants down. Penny saved penny earned etc. See if you can vet that practice assistance group, would hate to find out they’re bad on the back end.

If this job is in another state, you better start credentialing ASAP if you want to get going. It’s nice that you don’t have to negotiate insurance rates, but getting onto a full insurance panel after a move can take a year.

Do what works for you. If the other docs are happy and have stuck around, hopefully happy days for you too professionally. Keep the family in mind too.

 

[anonperson]

Been a member of SDN since Freshman year of college in 2006. It's been a while but I have always appreciated the advice.

My training has always been in large cities at major academic hospitals. Towards the end of fellowship I felt like less of a doctor and more of a technician than I felt even as a junior resident: Most days I was doing between 3-5 cases, 8-10 calls per month, 30-50 patients on my list(s), not enough time to get to know my patients, care for my complications. The pay sucked, the camaraderie sucked, god bless the residents and NPs who were fantastic. I found at the end of ACS fellowship that I was completely burned out, cynical against health systems, and as I was looking for jobs it was just more of the same everywhere I looked. I have kids and I just felt like I was going to be an indentured servant to whatever system I signed on with, with no real flexibility to dictate my time for my kids, nor the ability to bill for the services that I provided.

I was gung-ho academics/research entering fellowship but there was so little time and support for research as a fellow that my productivity has fallen off and I'm not in any place to apply for grants or negotiate protected time. I didn't sign on for an academic job and am now working per diem (same big hospital chain, not making great money, clearly no career trajectory from this position) but the week on week off schedule is helping me to feel normal after many years of not feeling normal (granted I've only been done with training for 6 weeks). I will say It felt great getting to take my kids to their first day of school.

I have a job opportunity that I am strongly considering and would love the sage advice of those more seasoned (sorry doctors in training, I don't want your 2 cents). I have a rural job opportunity, not academic, in paradise. A mostly poor population but there are a lot of tourists that come through needing EGS services. The trauma is great, I'll get a reasonable stipend for taking call (1 week on 24/7 q4 weeks). They need an intensivist (5 bed ICU, low acuity mostly medicine pts, would split with the other intensivist staffing 2 weeks on 2 weeks off; the hospitalist/nocturist would do consults/admissions/nursing issues for most overnight issues) and I would otherwise set up a private practice general surgery gig covering broad spectrum general surgery and basic vascular (a lot of diabetes so wounds and dialysis access will be a big part of my practice). The other surgeons at the hospital are fabulous and even though each works as an independent private practitioner the camaraderie is excellent. There is even a small surgery center that I will be able to do smaller cases at (lap hernias, lumps and bumps, etc).

The setup: Private practice LLC. Private billing for all cases, consults, procedures, ICU work. Medicaid pays medicare rates. The major insurer for the community pays 3x medicare. All docs in the community have signed on to a PPO so I don't have to negotiate contracts with insurance. About 1/3rd of the community is uninsured. Outpatient will use Charm EMR (cheap) inpatient Meditech (ugh), 3rd party biller, one of the surgeons will sublease clinic space to me 1-2x/week. The hospital will supply the wound care center and I'll have a WOC RN twice a week (working on her APRN but will be 2 years before she can functioning independently).

The pros: The hours will be much better. I will have flexibility. I will live in a beautiful location. I really like the community feel of the hospital. Very underserved patient population and there is a lot of medical need. I'll feel like a doctor again. The private school for my kids is fabulous.

The cons: I have only ever lived in cities and trained at major academic institutions. WTF do I know about rural living, building a practice, billing. There is a not insignificant chance that I move my family down and fail (I have no support whatsoever). I guess then I come back and find a job as an ACS surgeon somewhere? Hard on the kiddos (and my wife) to move so much. How much of my care is not going to be reimbursed? What is the transition like going from a hospital with every resource (sub specialist consult services, ECMO, Da Vinci's, IR... the basic academic stuff) to a place that has very little to none of these.

Should I take the risk? 99% of me says yes. What do you all think?

Are they subsidizing your income for the first few years while you build your practice?

Other than the call stipend which theoretically could get paid quickly but when you bill insurance there will be a long delay.

Some insurance companies will purposely drag their feet regarding payment.

How is the hospital going to make you financially whole when caring for uninsured patients? You should be getting paid for this work. Otherwise you are taking on liability for no pay.

Also, be wary of the billing companies. They will often be terrible. There will be a certain percentage of insured patients they won't collect from and probably won't push the issue. They'll go after the low hanging fruit, typically, and move on.

You should be making more if you're moving to a under served area.

If this is a non profit hospital, feel free to look up their tax filing information to see how much money the CEO, CFO, and CMO are making. The money is surprising.

 

[MalibuPreMD]

Thanks for all of the replies. The major issue that I will need to negotiate is payment for the uninsured in the ICU setting and how billing will work with the hospitalists. The hospital is nonprofit and the wages paid to the CEO and CMO are <25% percentile compared to CEO/CMO locally.

For population it's ~60k with many tourists coming throughout the year. The medicaid + uninsured rate in 2021 was 30% of the total population.

By great trauma, it's low in volume but the penetrating:blunt ratio is much higher than where I currently work (where majority of trauma volume equates to old folks with ground level falls and small head bleeds on anticoagulants). There is an illicit drug trade probably supported by the high number of tourists that leads to penetrating injuries.

Wife is on board! The primary goal of this (ad)venture is to take control over our lives after 10 years of subservience. There is risk involved, particularly as the private practice ACS doc isn't a well described entity probably for a reason, but the possibility of control is alluring and I have a wide skill set that can hopefully provide value - both to the community and to a startup private practice.

I appreciate the advice above. Thank you!

 

[MalibuPreMD]

update:

wanted to let you all know that the contract is signed. Will update the thread with mistakes made and lessons learned. Starting Jan 2025.
Thanks again for the help!

 

[anonperson]

update:

wanted to let you all know that the contract is signed. Will update the thread with mistakes made and lessons learned. Starting Jan 2025.
Thanks again for the help!

What's the pay situation?

You have guaranteed salary to start? What happens when you care for an uninsured patient?

 

[MalibuPreMD]

Salary ~50-60% of academic junior attending trauma surgeon, renegotiate after 1 year
I will bill for all professional services provided (ICU, inpatient EGS with 1 call week/ month)
I will also have a small elective general surgery / wound care practice

 

[Dr.LeoSpaceman]

Good luck to you. But I will just say, that comp sounds low. I'm in an academic practice, but back of the envelope calculation, if you're making half an academic trauma attending in salary, you're going to need like 5000-6000 RVUs (depending on conversion factor and exact salary numbers) to get to 100% of an academic job. That sounds...not great.

 

[LucidSplash]

Good luck to you. But I will just say, that comp sounds low. I'm in an academic practice, but back of the envelope calculation, if you're making half an academic trauma attending in salary, you're going to need like 5000-6000 RVUs (depending on conversion factor and exact salary numbers) to get to 100% of an academic job. That sounds...not great.

Agreed. And still not sure how they are being compensated for the RVUs for all the uninsured trauma patients. Are the RVUs counted by collection based or billed based? I’m not a fan of heavily production-based comp structures anyway, especially in terms of specialties with a high degree of ED consults/emergency procedures and un-and under-insured patients. But this seems an especially bad set up. Best of luck to OP. Hope it works out better than it seems here.