Any advice for the job search?

[dermfirstyear]

So I'm finishing up residency and looking for jobs. Any advice?

One of the specifics I'm wondering about is tail insurance. I want to go to a big city for a few years, I know the market there is saturated and the job might not be as ideal (I'll work more, get paid less, etc) but I want to do it just for the lifestyle of living there.

Do most malpractices include tail insurance? Is this something I need to get them to pay for?

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[Skindoc83]

Anything and everything is negotiable. A lot of contracts will stipulate that if you leave, you are responsible for the tail but if they let you go, they will pick up the tail. Honestly, for a first job I wouldn’t worry too much about tail insurance since that only matters if you leave that job. Should you choose to leave your first job, I would negotiate with your second employer that they should pick up your tail. But check what the terms of your residency coverage is. Some residencies, like Ohio state, require you to pay for tail coverage. If that’s the case, negotiate for your employer to pick this up since this can be in the ten or twenty thousand dollars.

I tell people not to worry so much about their first job, because you don’t know what’s important to you and what are or are not deal breakers. Most people don’t stick with their first job. I would advise against joining a PE group because I think they’re a scourge to our field. I would avoid any jobs that have very complicated bonus systems, because those are designed to exploit you. Avoid jobs that employ family, for example the wife is a derm and the husband is an office manager, they will never take your side. If providers have left the practice, reach out to them and see why they left and get the inside scoop. Also find out if you are expected to oversee mid levels, and if so, how are you compensated? Don’t be swayed by fancy offices or a million lasers. These things aren’t free and may suggest poor business acumen and very high overhead. If you’re looking for a job in a competitive area, I would avoid the job boards and cold call every practice in the area.

 

[derm_skyisnotfalling]

So basically don't work anywhere based on your criteria...lol. Sounds like your solution is to start your own practice then. Even university and managed health care systemic put golden handcuffs on with their bonuses. Basically, let's recap:

Managed health care - Bonus structures exploit you with golden handcuffs/pseudo-probation period and shut down your ability to do anything outside of their system when it comes to consulting/derm.
PE groups - Scourge
University - one of the most complicated bonus structures typically to the point that you have no idea what is going on...so they are out.
VA - there's some promise based on your criteria.
Private practice - be very careful if there are family involved (I agree with this advice) or if you have to oversee midlevels

That leaves starting your own practice as the winner, which is probably not the right answer in most of the cases of the graduating residents.

Oh and have one foot out the door at your first job and best to start at the VA.

Clearly the OP is openly stating that lifestyle factors are going to dominate and he/she just wants to be there for a few years. In this case, there are a few good options. A health-care managed system, VA, PE groups, large integrated systems, or Academics are fine choices. Some health care systems will put golden handcuffs on you with a multii-year provision on payback for "bonuses" so beware.

Finally, everything is not negotiable and you have to be reasonable. If you are entering an academic setting or the VA, many things are not negotiable the way they would be at a private practice.

 

[Earl Simmons]

How reasonable is it to start up a derm practice (solo) upon graduating? What are the barriers in place?

 

[Skindoc83]

How reasonable is it to start up a derm practice (solo) upon graduating? What are the barriers in place?

Assuming that you’re talking about starting a practice that accepts insurance rather than a cash only practice, the biggest barriers are cost and not knowing what you don’t know about running a medical practice. There are still a lot of derms starting up their own practice with great success. In this day and age, I would recommend running a cash only practice since the overhead involved in running a solo practice that takes insurance is huge. You need to have in house billers or subcontract out your billing and these services only seem to get more expensive each year while reimbursement stagnates or goes down. You will also likely have trouble attracting patients for awhile while still having high overhead. The beauty of running a cash only practice is that when you start, you can be the only employee. Initially you will only have a few patients a day or even a week. You answer your own phones, room your own patients, etc but if your only expenses are rent and supplies it’s very manageable and feasible. You post all of your prices online so there is no confusion or haggling about the cost of a biopsy or 15 min apt. I usually recommend that a new grad join a group or practice for two years to learn the behind the scenes info before going off on her own. But I think the future of solo practitioners is cash only.

 

[Hotei]

Assuming that you’re talking about starting a practice that accepts insurance rather than a cash only practice, the biggest barriers are cost and not knowing what you don’t know about running a medical practice. There are still a lot of derms starting up their own practice with great success. In this day and age, I would recommend running a cash only practice since the overhead involved in running a solo practice that takes insurance is huge. You need to have in house billers or subcontract out your billing and these services only seem to get more expensive each year while reimbursement stagnates or goes down. You will also likely have trouble attracting patients for awhile while still having high overhead. The beauty of running a cash only practice is that when you start, you can be the only employee. Initially you will only have a few patients a day or even a week. You answer your own phones, room your own patients, etc but if your only expenses are rent and supplies it’s very manageable and feasible. You post all of your prices online so there is no confusion or haggling about the cost of a biopsy or 15 min apt. I usually recommend that a new grad join a group or practice for two years to learn the behind the scenes info before going off on her own. But I think the future of solo practitioners is cash only.

Sorry if I am getting off topic. Would you mind elaborating on the general categories of things to pick up when learning behind the scenes info? Is it staff training, or supplies negotiation? Thank you.

 

[asmallchild]

Sorry if I am getting off topic. Would you mind elaborating on the general categories of things to pick up when learning behind the scenes info? Is it staff training, or supplies negotiation? Thank you.

I've heard mixed things. The advice I usually get from older docs is to just jump into solo practice from the very beginning if you are interested in doing so. There will always be a learning curve and you might as well start from Day 1.

I think it is still helpful to join a group practice for a year or two as Skindoc83 mentioned to pick up certain things.

It's many of the things you've mentioned:

- how to train the staff
- how to deal with the hiring/firing of staff
- how to manage conflicts with staff
- what protocols or pathways did the group utilize that you liked?
- what protocols or pathways did the group utilize that you could improve on?
- what supplies do you need?
- what procedures do you like to do and want to see? are there any you no longer want to do?
- what types of patients do you like to see? are there any you no longer want to see?
- what kind of EMR (if any) do you want?
- how do you want to handle billing if you aren't going cash-only?
- how did your group advertise? was it successful?
- what was the protocol for handling patients calls? call in general?
- how many rooms do you want to work out of? how many MAs do you need? will you have the patient volume to pay for these?

 

[Slack3r]

Any particular questions we should be thinking about when looking for positions? Specifically, gen derm positions in PP.

 

[Slack3r]

Assuming that you’re talking about starting a practice that accepts insurance rather than a cash only practice, the biggest barriers are cost and not knowing what you don’t know about running a medical practice. There are still a lot of derms starting up their own practice with great success. In this day and age, I would recommend running a cash only practice since the overhead involved in running a solo practice that takes insurance is huge. You need to have in house billers or subcontract out your billing and these services only seem to get more expensive each year while reimbursement stagnates or goes down. You will also likely have trouble attracting patients for awhile while still having high overhead. The beauty of running a cash only practice is that when you start, you can be the only employee. Initially you will only have a few patients a day or even a week. You answer your own phones, room your own patients, etc but if your only expenses are rent and supplies it’s very manageable and feasible. You post all of your prices online so there is no confusion or haggling about the cost of a biopsy or 15 min apt. I usually recommend that a new grad join a group or practice for two years to learn the behind the scenes info before going off on her own. But I think the future of solo practitioners is cash only.

How do you handle path in a cash only practice? Are you reading your own slides and billing the patient? Seems like that would be a hard sell on top of a ~$100 biopsy. Or do you send to an outside lab and have them bill the patient’s insurance? Do you provide them with a superbill?

Also, what makes someone want to come to a new practice and pay cash, when any number of places down the street will take their insurance? Certainly seems easier as far as overhead when starting our, but I’d have to imagine you’d take much longer to ramp up to speed if you’re cash only from the onset.

 

[Skindoc83]

For path you list your prices just like you would list your price for the biopsy, 30 min patient visit, benign destruction, etc. For instance, you tell them biopsy is $150 with path billing an additional $150 with the possibility of more cost if they need special stains. Most cash practices contract with an outside lab to read the slides and bill the patient your agreed upon cost (I.e. 150). But if you want to read your own path you could just Bundle the cost as $300 for biopsy and path. A lot of practices will offer the patient a Super bill that they can submit to their insurance.

There are a lot of reasons to see a cash only doc. Some patients like the fact that the doc will spend more time with them (I.e. 30 mins versus say 7-10). Sometimes there is a dearth of available derms in the area and the patient doesn’t want to wait 6 months to be seen. Some are young folks that just want to treat acne but don’t have insurance. It usually takes longer to build up a cash practice, but the nice part is that you can often better absorb the cost of being slow since your overhead is usually quite low. As such, you can afford to see fewer patients while making a similar income.