Borrowing Max Tuition and its associated debt structure

[heybrother]

When I initially applied to podiatry school I believe the tuition was like $28K at DMU. It now exceeds $40K. While I had no basis for it at the time, I had this lingering suspicion in the back of my mind that there was a tuition point that podiatry would ultimately reach where they would price themselves out of students.

A historic poster of this forum recently mentioned that they had reached $400K in debt. What's fascinating to me about this is the idea of what I'll call critical debt which more commonly is applied to companies or businesses. Essentially, an unsustainable debt burden which you will not be able to pay down and in the case of student loans will have to pursue forgiveness for.

I concede several things:
-New laws will continue to be passed which may change payment structures
-Interest rates have been in substantial fluctuation with some prior borrowers having low rates during some of their individual years
-I am not a math person
-Some of the values have been smoothed for convenience. That said, historically podiatry schools increase tuition every year.
-Loans are borrowed usually in semesters but I've simply conglomerated them as years
-I've used the maximum tuition listed on one school's website. Not everyone borrows that amount. That said - I believe the school simply views this as the default amount.
-https://www.dmu.edu/financial-aid/cost-of-attendance-budget-information/
-I didn't choose DMU to beat them up. I chose it because historically when I looked at some other schools they masked their values/made it hard to see what would be borrowed.'
-I've chosen a straight interest rate of 6.5%. It may actually be worse than that (currently 6.54%, in fact certain loans are 7.54%...)

Year 1 - $70,345. New Interest - $4550 but it doesn't capitalize.
Year 2 - $72164, Running Cost - $142,509, new interest $9263 but it doesn't capitalize
Year 3 - $67,863, Running Cost - $210,372, new interest $13,674 but it doesn't capitalize
Year 4 - $77,245, Running Cost - $287,617, new interest $18,695.

At this point - your interest capitalizes and merges over into the principal column. To the best of my memory at this point you haven't experienced compounded interest.

New Total - $333,821 with $287,617 of that having been borrowed and the rest interest.

At this point - most people aren't going to be able to go to a payment plan that touches principal because a 20-year payment structure on $333K at 6.5% requires a monthly payment $2485 according to a mortgage calculator.

You'll be on some sort of payment plan. I've selected a fake value of 10% of $55K for the next 3 years.

For each additional years assuming no further capitalization while in residency you will achieve $21,698 in new debt and make a payment of $5500 against it.

You will therefore graduate resident with a total principal + interest debt of $382,417.

Your new debt will generate $24,857 a year in new interest which you will have to overcome with payments.

A 20 year payment plan will require a monthly payment of $2851 which comes out to ~$34K a year.

By paying $34K a year on this debt you will in your first year as an attending pay off $9354 in principal and have 19 more years to go.

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[Pronation]

Great post. Anyone thinking of podiatry and taking a loan should consider their income for the next 20 years as salary minus $34k.

So here’s the reality… anything less than $180k per year is hot garbage for ROI on 7 years of post undergrad training. In fact it’s so bad that you’d be better off after HS going straight into a trade such as plumbing or electric.

 

[air bud]

When I initially applied to podiatry school I believe the tuition was like $28K at DMU. It now exceeds $40K. While I had no basis for it at the time, I had this lingering suspicion in the back of my mind that there was a tuition point that podiatry would ultimately reach where they would price themselves out of students.

A historic poster of this forum recently mentioned that they had reached $400K in debt. What's fascinating to me about this is the idea of what I'll call critical debt which more commonly is applied to companies or businesses. Essentially, an unsustainable debt burden which you will not be able to pay down and in the case of student loans will have to pursue forgiveness for.

I concede several things:
-New laws will continue to be passed which may change payment structures
-Interest rates have been in substantial fluctuation with some prior borrowers having low rates during some of their individual years
-I am not a math person
-Some of the values have been smoothed for convenience. That said, historically podiatry schools increase tuition every year.
-Loans are borrowed usually in semesters but I've simply conglomerated them as years
-I've used the maximum tuition listed on one school's website. Not everyone borrows that amount. That said - I believe the school simply views this as the default amount.
-https://www.dmu.edu/financial-aid/cost-of-attendance-budget-information/
-I didn't choose DMU to beat them up. I chose it because historically when I looked at some other schools they masked their values/made it hard to see what would be borrowed.'
-I've chosen a straight interest rate of 6.5%. It may actually be worse than that (currently 6.54%, in fact certain loans are 7.54%...)

Year 1 - $70,345. New Interest - $4550 but it doesn't capitalize.
Year 2 - $72164, Running Cost - $142,509, new interest $9263 but it doesn't capitalize
Year 3 - $67,863, Running Cost - $210,372, new interest $13,674 but it doesn't capitalize
Year 4 - $77,245, Running Cost - $287,617, new interest $18,695.

At this point - your interest capitalizes and merges over into the principal column. To the best of my memory at this point you haven't experienced compounded interest.

New Total - $333,821 with $287,617 of that having been borrowed and the rest interest.

At this point - most people aren't going to be able to go to a payment plan that touches principal because a 20-year payment structure on $333K at 6.5% requires a monthly payment $2485 according to a mortgage calculator.

You'll be on some sort of payment plan. I've selected a fake value of 10% of $55K for the next 3 years.

For each additional years assuming no further capitalization while in residency you will achieve $21,698 in new debt and make a payment of $5500 against it.

You will therefore graduate resident with a total principal + interest debt of $382,417.

Your new debt will generate $24,857 a year in new interest which you will have to overcome with payments.

A 20 year payment plan will require a monthly payment of $2851 which comes out to ~$34K a year.

By paying $34K a year on this debt you will in your first year as an attending pay off $9354 in principal and have 19 more years to go.

So I want to be a doctor but have a 2.9gpa. you are saying I should go to podiatrist school?

 

[heybrother]

So I want to be a doctor but have a 2.9gpa. you are saying I should go to podiatrist school?

Hi airbud. I recommend you find yourself a mentor through the APMA. Podiatry is a wonderful career in which you can make people feel better right away. Some people, in the Podiatry Management magazine, say podiatry is the best kept secret in medicine even though other pathways are far cheaper, pay better, have shorter training periods, are in greater demand, can find jobs anywhere, and have far fewer scope of practice problems. Podiatry allows you diverse practice options such as podiatric medicine and podiatric surgery. Keep in mind though that if you are at a hospital when someone says "they need a surgeon" they don't mean you. Also, podiatric medicine doesn't really mean "medicine" in the traditional sense like managing diabetes, or prescribing insulin or blood pressure medications, even though all of the patients you are treating will be on these medications. Podiatry has a lot of the things that medicine has - like tests, organizations, schools and national leadership, but these things are all a little bit different and more focused on personal enrichment. Don't fret - we've come a long way. If you are still interested we would love to have you shadow but know that there's a seat at a podiatry school with your name on it even if you don't. If you are by chance a high schooler know that you are the core audience we are targeting to get you hooked early. Did we mention you can be a doctor and a surgeon.

Sincerely,
Podiatry.

 

[wakaflocka88]

Hi airbud. I recommend you find yourself a mentor through the APMA. Podiatry is a wonderful career in which you can make people feel better right away. Some people, in the Podiatry Management magazine, say podiatry is the best kept secret in medicine even though other pathways are far cheaper, pay better, have shorter training periods, are in greater demand, can find jobs anywhere, and have far fewer scope of practice problems. Podiatry allows you diverse practice options such as podiatric medicine and podiatric surgery. Keep in mind though that if you are at a hospital when someone says "they need a surgeon" they don't mean you. Also, podiatric medicine doesn't really mean "medicine" in the traditional sense like managing diabetes, or prescribing insulin or blood pressure medications, even though all of the patients you are treating will be on these medications. Podiatry has a lot of the things that medicine has - like tests, organizations, schools and national leadership, but these things are all a little bit different and more focused on personal enrichment. Don't fret - we've come a long way. If you are still interested we would love to have you shadow but know that there's a seat at a podiatry school with your name on it even if you don't. If you are by chance a high schooler know that you are the core audience we are targeting to get you hooked early. Did we mention you can be a doctor and a surgeon.

Sincerely,
Podiatry.

You single handedly crushed every aspiring students dream on the internet and on instagram. But that’s okay. Lowell Weil Junior will keep telling everyone podiatry is such a secret gem of a specialty and don’t listen to this pitter patter of negativity. Speaking of Lowell Junior, what the heck does his “fellowship” even entail? 12 months of learning how to unbundle a hammer toe repair with his osteotomies?

 

[GreenHousePub]

You guys are so salty about your jobs when I love what I do and keep killing it every damn day

 

[air bud]

You guys are so salty about your jobs when I love what I do and keep killing it every damn day

No that's what is funny, so many people on here are killing it....but just trying to do our best to gatekeep. Don't ruin this for us bro.

 

[Feli]

It is pretty much up to the Fed govt. Whatever govt will borrow, the schools will charge that... and then complain they need a bit more.
Welcome to govt funding/lending of anything... has anyone noticed price to mail packages has roughly doubled last few years?

"Students need more, they can't quite afford tuition + books + living" = raise the max loans
(repeat cycle, repeat, repeat)

From tuition to housing to everything else, if govt didn't back the loans, there are suddenly very few buyers. MD school cost was a lot more reasonable when people needed real money via scholarship, family $, or private loan to attend. Now, anyone who can get in gets the funds with a signature, and the debt is growing at magnificent rates. There are no easy answers.

 

[dtrack22]

You guys are so salty about your jobs when I love what I do and keep killing it every damn day

I’m not salty about my job at all. I’m salty about having money stolen from me for the first several years of my career. By other podiatrists. I’m realistic in the fact that I can’t just open up an email to find 6-7 new job opportunities every day as a podiatrist. I understand that any PA in the country can make $100 per hour but only a % of podiatrists will come anywhere near that for at least a few years after finishing residency. Based on number of applications to most employed positions that I have some personal/inside knowledge of, I know that we have an oversupply of Podiatrists at the moment. And I get that when supply outpaces demand, wages can remain stagnant.

You can have a great job and still recognize the fact that at some point the cost of becoming a podiatrist will not be worth it financially for a significant number of graduates. Certain medical specialties are seeing pay stagnate or even get cut because of oversupply and the docs warning people about what they are seeing are probably still doing well working in an ED making $400k on 10-15 shifts per month. It has nothing to do with being salty and everything to do with understanding and explaining the reality of this profession at the moment.

 

[HaimFeldman]

Every associate podiatrist needs to rise up together and seize the means of production from all the bourgeoise private practice owners.

 

[GreenHousePub]

Every associate podiatrist needs to rise up together and seize the means of production from all the bourgeoise private practice owners.

Time to unionize

 

[shadesofgrey]

Every associate podiatrist needs to rise up together and seize the means of production from all the bourgeoise private practice owners.

As someone who just became a partner at a greedy PP, can we tamp down on the unionizing of associates, at least till I pay my student loans off. In a few years, once they are paid off then I'll pay a fair wage. You can trust me to do the right thing, I'm on SDN! I can assure you that I won't profit for years while stringing my associate along with the promise of one day buying in at a overly inflated price.

On a serious note, we have been looking into hiring a new associate and getting the older docs to pay a decent salary is harder than expected. They just have no concept of the debt graduating residents are coming out with and literally cannot belief the offers that hospitals are offering. I had to argue about how embarrassed I would be to offer someone their initial offer to help them realize how bad their suggested salary was.

 

[de Ribas]

Look at gaswork site. There are like 7k open CRNA jobs all paying between 200-300k. A lot of them are no call. Lots of time off. At one hospital where I did rotations, their CRNAs get 250k for start, 8 weeks off and they usually leave anywhere between 10am-12pm on most days if not their call turn. Usually one MDA and one CRNA stay after 1pm to run 1 OR room. Literally anyone's dream job.

 

[deleted1138023]

travel nurses are easily making $3,000 a week and working 3 days a week. nuff said

 

[CutsWithFury]

You guys are so salty about your jobs when I love what I do and keep killing it every damn day

There’s zero chance you love what you do in podiatry everyday. Stop sniffing the phenol

 

[Redsting]

-I've chosen a straight interest rate of 6.5%. It may actually be worse than that (currently 6.54%, in fact certain loans are 7.54%...)

You will therefore graduate resident with a total principal + interest debt of $382,417.

Your new debt will generate $24,857 a year in new interest which you will have to overcome with payments.

A 20 year payment plan will require a monthly payment of $2851 which comes out to ~$34K a year.

By paying $34K a year on this debt you will in your first year as an attending pay off $9354 in principal and have 19 more years to go.

What's crazy is when I finished residency I had almost that exact number in student loans $382k. My tuition was cheaper than what you quoted but I was an idiot cause I took out a lot of cost of living loans. Because "I'm going to make doctor money". I got lucky. I am 4 years out and I have 50k left on them. They should be done around the new year.
I have friends/co residents who had around that much and a lot of them have opted to go for the 20 year forgiveness with a huge tax bomb. They are hoping to buy into something and then they may get aggressive with it.
I am trying to pay off these loans ASAP and start putting all the money to investments cause who knows how long this can go on. Once my loans are paid off, as long as I can pay the mortgage and buy food then if something happens I can squeeze by. Also, once we are even more saturated then we are now (thanks Harkless) who knows how long Ill be able to keep putting this money away.
I should have gone into something tech. I am learning programing now, who knows if that will come in handy later on or not. I also think about other revenue streams so that I won't be financially reliant on Podiatry.

The schools are getting rich off of us. The federal government is allowing it to happen by signing a blank check every year to them. Then they charge interest rates I see on credit cards. As long as the crazy interest rates on student loans are going on (and the federal government is involved), people will continue to be held down.

 

[CutsWithFury]

What's crazy is when I finished residency I had almost that exact number in student loans $382k. My tuition was cheaper than what you quoted but I was an idiot cause I took out a lot of cost of living loans. Because "I'm going to make doctor money". I got lucky. I am 4 years out and I have 50k left on them. They should be done around the new year.
I have friends/co residents who had around that much and a lot of them have opted to go for the 20 year forgiveness with a huge tax bomb. They are hoping to buy into something and then they may get aggressive with it.
I am trying to pay off these loans ASAP and start putting all the money to investments cause who knows how long this can go on. Once my loans are paid off, as long as I can pay the mortgage and buy food then if something happens I can squeeze by. Also, once we are even more saturated then we are now (thanks Harkless) who knows how long Ill be able to keep putting this money away.
I should have gone into something tech. I am learning programing now, who knows if that will come in handy later on or not. I also think about other revenue streams so that I won't be financially reliant on Podiatry.

The schools are getting rich off of us. The federal government is allowing it to happen by signing a blank check every year to them. Then they charge interest rates I see on credit cards. As long as the crazy interest rates on student loans are going on (and the federal government is involved), people will continue to be held down.

The schools are crapping themselves with less applicants per year and now two new podiatry schools to contend with for applicants. This profession is insane.

 

[619]

There’s zero chance you love what you do in podiatry everyday.

I personally love my general everyday podiatry practice. Maybe this is due to just the way I practice. I deflect away a lot of trouble patient. Once I see a patient first visit and I sense I can't help them, I am quick to let them know at the first visit.

Example is patients with neuropathy or chronic leg swelling who go from doctor to doctor. I let them know first visit that I can't help and I discharge. I am not interested in doing a full work-up for neuropathy or leg swelling. Same goes to patients coming in for surgery consult and there is nothing to fix. They can blame their bunion for the general burning foot pain but I know fixing the bunion is not going to solve the burning foot pain. I refuse to do surgery on those. Daily decisions like that makes a stress free practice and I get to enjoy podiatry.

I enjoy treating bunions, hammertoes, ingrown nails, warts, sprain, acute gout, heel pain, infections, MSK pathologies etc. Personally, podiatry has been good and fulfilling to me thus far.

 

[Pronation]

I personally love my general everyday podiatry practice. Maybe this is due to just the way I practice. I deflect away a lot of trouble patient. Once I see a patient first visit and I sense I can't help them, I am quick to let them know at the first visit.

Example is patients with neuropathy or chronic leg swelling who go from doctor to doctor. I let them know first visit that I can't help and I discharge. I am not interested in doing a full work-up for neuropathy or leg swelling. Same goes to patients coming in for surgery consult and there is nothing to fix. They can blame their bunion for the general burning foot pain but I know fixing the bunion is not going to solve the burning foot pain. I refuse to do surgery on those. Daily decisions like that makes a stress free practice and I get to enjoy podiatry.

I enjoy treating bunions, hammertoes, ingrown nails, warts, sprain, acute gout, heel pain, infections, MSK pathologies etc. Personally, podiatry has been good and fulfilling to me thus far.

Would you say that you mainly do toe surgery? Maybe the occasional plantar fascia release?

 

[GreenHousePub]

travel nurses are easily making $3,000 a week and working 3 days a week. nuff said

Still? I knew they were back in COVID era.

 

[619]

Would you say that you mainly do toe surgery? Maybe the occasional plantar fascia release?

I went to a strong surgical problem and did big cases when I was an associate in a group and we had the resources and staff. Since going solo, I am not interested in that anymore (because I only have 2 office staff and no MA) and I don't want to deal with a long post-op course with endless dressing change and cast change. To answer your question I do not only do toe surgeries, I still do the ankle ligament repair, PT/peroneal tendon repair, soft tissue mass excision, ganglion cysts, retro calc etc. However my favorite I would say is the 1st MPJ fusion.

I also enjoy the occasional diabetic surgical hospital consults for toe apms, I&D, met head resection etc because they can follow up at the hospital wound care center upon discharge except a few select patient that follow up with me clinic after being discharged from the hospital. I don't take call at my hospital but I occasional get surgical consults from hospitalists that know me and hit me up on the hospital texting app.

 

[PeaJay]

I personally love my general everyday podiatry practice. Maybe this is due to just the way I practice. I deflect away a lot of trouble patient. Once I see a patient first visit and I sense I can't help them, I am quick to let them know at the first visit.

Example is patients with neuropathy or chronic leg swelling who go from doctor to doctor. I let them know first visit that I can't help and I discharge. I am not interested in doing a full work-up for neuropathy or leg swelling. Same goes to patients coming in for surgery consult and there is nothing to fix. They can blame their bunion for the general burning foot pain but I know fixing the bunion is not going to solve the burning foot pain. I refuse to do surgery on those. Daily decisions like that makes a stress free practice and I get to enjoy podiatry.

I enjoy treating bunions, hammertoes, ingrown nails, warts, sprain, acute gout, heel pain, infections, MSK pathologies etc. Personally, podiatry has been good and fulfilling to me thus far.

It is nice to hear someone actually have logical surgical criteria. Just because someone has a problem that could be treated surgically does not mean they would be best served by surgery.

I talk people out of surgery everyday. It is not because I don’t like doing surgery, but I am not going to make indications. I rather treat people ethically than think of them as my next case. I am not going to fix a bunion because they are having general pain from fat pad atrophy, ect.

 

[heybrother]

Imagine if you operated on every person who had a plantar plate "rupture" and some toe drift.

 

[air bud]

I went to a strong surgical problem and did big cases when I was an associate in a group and we had the resources and staff. Since going solo, I am not interested in that anymore (because I only have 2 office staff and no MA) and I don't want to deal with a long post-op course with endless dressing change and cast change. To answer your question I do not only do toe surgeries, I still do the ankle ligament repair, PT/peroneal tendon repair, soft tissue mass excision, ganglion cysts, retro calc etc. However my favorite I would say is the 1st MPJ fusion.

I also enjoy the occasional diabetic surgical hospital consults for toe apms, I&D, met head resection etc because they can follow up at the hospital wound care center upon discharge except a few select patient that follow up with me clinic after being discharged from the hospital. I don't take call at my hospital but I occasional get surgical consults from hospitalists that know me and hit me up on the hospital texting app.

2 office staff and no MA.
Color me intrigued I have some questions coming your way.....

 

[dtrack22]

Imagine if you operated on every person who had a plantar plate "rupture" and some toe drift.

I would prefer to operate on zero plantar plates and drifted toes. I suck at them.

 

[heybrother]

I would prefer to operate on zero plantar plates and drifted toes. I suck at them.

I had an educational handout that I believe ACFAS made about plantar plate ruptures. It was actually pretty decent, but it had some language in it that I thought strongly suggested the patient would require surgery if their toe drifted. I remade it and removed all that language.

Randy Clements made a joke at TPMA last year that I hadn't heard before about how if he caught his partner in bed with his wife he'd still hate the 2nd toe more.

 

[Feli]

I had an educational handout that I believe ACFAS made about plantar plate ruptures. It was actually pretty decent, but it had some language in it that I thought strongly suggested the patient would require surgery if their toe drifted. I remade it and removed all that language.

Randy Clements made a joke at TPMA last year that I hadn't heard before about how if he caught his partner in bed with his wife he'd still hate the 2nd toe more.

It is a super tough pathology to get right and keep right. I would say it's up there with calc fx and Lapidus in terms of fairly easy to do but very hard to get just right (Charcot is hard... but only because the pts are totally unhealthy). In office, I use the FootHealthFacts.org handout 'capsulitis of the second toe.'

I always get the first ray correct, then shorten any that have PDS/plant plate/drift with met osteotomy to shorten and sometimes T&C, sometimes PIPJ fusion, sometimes EHL lengthen... shorten the rays a LOT. I sometimes take out 5mm or more of 2nd met intentionally with feathering or even two weil cuts. I never pin the 2nd MPJ... I was trained - and believe that - if you need to, you should've shortened it more. Pinning is just kidding yourself that it's 'fixed' and will fail later when the wire is pulled. The main key to success on 2nd MPJ is probably telling them "it won't be perfect" at multiple pre and post op visits?

I don't understand the direct repair plantar plate... looks pretty, sounds ok... but likely does squat and rips first time they ever heel raise or even just walk in a regular shoe. I have no idea if the 'system' plate repair sets for that are even still a thing. They came out when I was in training and I may have done a few in residency, but it's one of those things that make such little sense that you don't need to go any further.

For 99% of cases of PDS/plantar plate, anyone who does isolated 2nd MPJ surgery should probably lose their BQ/BC (or now, their CAQ, lol). I think we tend to focus on the long 2nd ray in practice and meetings and etc... and totally underestimate the role of first ray hypermobile or sesamoid dislocation or HAV or whatever root cause is making 1st met not take the lion's share of the propulsion. Almost invariably, that's what's really causing the 2nd ray path. I do MPJ1 arthrodesis in at least half of my revisions of failed bunions (typically met osteotomy or McBrides... many of which also have 2nd toe drift), so that helps to set the foundation to fix the 2nd and get a balanced forefoot pretty well.

 

[Boba Foot]

Agreed. I think if CRNA was a residency, it would be competitive

One would have to think that CRNA as a profession will get nerfed eventually when more people are attracted to it, becomes over-populated and hospitals realize they can underpay them all.

 

[Feli]

One would have to think that CRNA as a profession will get nerfed eventually when more people are attracted to it, becomes over-populated and hospitals realize they can underpay them all.

They should open a school in south Texas?

CRNA is doing very well right now... taking only the best of the best RNs as students, limited programs, very competitive. I think their regulatory powers are doing very well - and have for decades. The same can't be said for pharma, PA, podiatry, etc... lax admissions, many grads, highly variable quality of finished products.

It all comes down to regulating the number of training programs. That's why Derm, ENT, plastics, and many other specialties always do so well. They could easily open up a bunch more programs... but they don't. They keep the USMLE standards high and best social/academic applicants, keep patient demand very strong. Conversely, it is no wonder that the ones with surplus of unfilled programs (peds, psych, etc) are also the lowest paid on avg.

 

[619]

2 office staff and no MA.
Color me intrigued I have some questions coming your way.....

When I was an associate at a pod practice in the satellite clinic I was sent to once a week, I had 2 staff, one up front and one MA at the back. I noticed that the MA actually slowed me down. Most of the practice bottle neck is upfront between checking in and checking out patients, answering phone calls, scheduling, faxing referral, insurance authorization etc. Once patient is roomed and I get my chart, it's an express way for me and I am good to go.

Even with 2 front staff, I still sometimes have to wait for the patient to be roomed (due to paperwork, phone calls etc). I recently taught one of my front staff how to take an x-ray and that helped me a lot in moving even quicker. I plan on hiring a 3rd staff soon but I will still want everyone to be trained up front first.

I want every phone call to be answered because that is how I scoop up a lot of new patients looking for same day or same week appointments. Patients call around and they want a live person on the phone, not an auto-machine.

All my back clinic stuff is set up by me and I know where everything is for my procedures from ingrown nail to biopsy to office I&D etc. Casting, DME fitting is all done by me. For booking surgery, I fill out all my pre-op paperwork etc. I do a lot of office procedures and I am very comfortable with no MA at the back. When I was an associate, one of the MA actually told me I am too independent because I don't ask them to get me things, I just go and grab it myself and set things up.

Any associate looking to go solo, you have to be 100% comfortable running the back by yourself. Ideally for a new solo practice, you want to start out with YOU and one staff and grow from there. Helps reduce payroll lol

 

[Scrantonicity]

When I was an associate at a pod practice in the satellite clinic I was sent to once a week, I had 2 staff, one up front and one MA at the back. I noticed that the MA actually slowed me down. Most of the practice bottle neck is upfront between checking in and checking out patients, answering phone calls, scheduling, faxing referral, insurance authorization etc. Once patient is roomed and I get my chart, it's an express way for me and I am good to go.

Even with 2 front staff, I still sometimes have to wait for the patient to be roomed (due to paperwork, phone calls etc). I recently taught one of my front staff how to take an x-ray and that helped me a lot in moving even quicker. I plan on hiring a 3rd staff soon but I will still want everyone to be trained up front first.

I want every phone call to be answered because that is how I scoop up a lot of new patients looking for same day or same week appointments. Patients call around and they want a live person on the phone, not an auto-machine.

All my back clinic stuff is set up by me and I know where everything is for my procedures from ingrown nail to biopsy to office I&D etc. Casting, DME fitting is all done by me. For booking surgery, I fill out all my pre-op paperwork etc. I do a lot of office procedures and I am very comfortable with no MA at the back. When I was an associate, one of the MA actually told me I am too independent because I don't ask them to get me things, I just go and grab it myself and set things up.

Any associate looking to go solo, you have to be 100% comfortable running the back by yourself. Ideally for a new solo practice, you want to start out with YOU and one staff and grow from there. Helps reduce payroll lol

I don't think there's any substitute to having an MA that can (based on the chief complaint and/or a brief interaction with the patient) have everything you'll need laid out for you. MA's that can't do that only slow me down, like you said. I don't need them after that--as long as everything is laid out I'm good...so mine takes X-rays and lays things out--then goes and answers phone calls.

Unfortunately it takes a good deal of training before MA's can "read your mind" and have what you need--and the ones that don't do it right will accuse you of being "too independent" because they watch you get it all yourself...then they think that's how you want it so they don't bother learning and doing it for you....so it can be a vicious cycle unless you communicate and train well. Otherwise it's just more warm bodies/dead weight that you're paying hourly for.

It's doable, what you're describing--and can even be "comfortable"--but it sure doesn't sound as efficient as it could be...

 

[Feli]

I don't think there's any substitute to having an MA that can (based on the chief complaint and/or a brief interaction with the patient) have everything you'll need laid out for you. MA's that can't do that only slow me down, like you said. I don't need them after that--as long as everything is laid out I'm good...so mine takes X-rays and lays things out--then goes and answers phone calls.

Unfortunately it takes a good deal of training before MA's can "read your mind" and have what you need--and the ones that don't do it right will accuse you of being "too independent" because they watch you get it all yourself...then they think that's how you want it so they don't bother learning and doing it for you....so it can be a vicious cycle unless you communicate and train well. Otherwise it's just more warm bodies/dead weight that you're paying hourly for.

It's doable, what you're describing--and can even be "comfortable"--but it sure doesn't sound as efficient as it could be...

I agree fully. Delegate, teach, delegate, delegate.

That setup ability is big, and it's also gross to be reaching into drawers, cabinets, dip tray, etc for instruments or inject or ACE wrap or etc after you've put gloves on and examined the pt, removed the bandage, debrided a wound, etc. That can definitely land you in bad Google reviews, or worse. The MA bridges that gap of grabbing anything you need for you while you do the procedure, exam, etc and build rapport - esp for new pts.

They can also grab OTC stuff, grab DME, do the Rx(s) on Surface or iPad, get the appropriate handout for pt edu, go get the MRI report, or chart review and check date of last Rx or DM shoes or whatever while you talk with the pt.

A practice without MA can work, but it's not for me. I couldn't see nearly my volume without them. They do 90% of the nail care, 90% of Rx, 90% of DME fitting/edu, etc. I can't be running back to get an ankle brace and showing the pt how to wear it, taking XR, etc. I fully expect the bandage off and bandage supplies in the tray, verruca setup, callus setup, ingrown setup, biopsy setup, etc ready in the tray or on mayo when I walk in.

It is mainly just a difference of if you want to see 10-15 per day on your own or 20-30+ daily with MA(s). Either can work. I have seen both done successfully. Some docs do the autoclaving, instrument packing, DME restocking, ordering, XR taking, etc all on their own... I would never do that past a startup clinic for a year or so. Once I have 10+ pt per day, my goal is to have the MAs do everything reasonably possible (non-invasive) so that the doc can just do exam, procedures with sharps, read XRs, make the plan, edu the pt, etc. You will never get past ~20pt per day otherwise. Basically, goal is doc only does things that reasonably require doc to do them. Realize that your time is worth $250-500+ per hour revenue generation, and if anything you do can be hired out for less than that, then do it! Ortho or Cards is basically the best example with the docs basically only popping in to greet and make the plan.... typically very high staffing and high pt volume. You'd very rarely see the MD them self ever put a cast on, hook a pt for EKG, imput Rx themself, etc.

 

[BoneWizard]

You'll be on some sort of payment plan. I've selected a fake value of 10% of $55K for the next 3 years.

For each additional years assuming no further capitalization while in residency you will achieve $21,698 in new debt and make a payment of $5500 against it.

You will therefore graduate resident with a total principal + interest debt of $382,417.

Your new debt will generate $24,857 a year in new interest which you will have to overcome with payments.

A 20 year payment plan will require a monthly payment of $2851 which comes out to ~$34K a year.

By paying $34K a year on this debt you will in your first year as an attending pay off $9354 in principal and have 19 more years to go.

You can do REPAYE which is 10% of discretionary income or $3,500/yr on $55,000 salary. It comes with a 50% interest subsidy for the first 3 years. If you have $25,000 annual interest, you paid $3,500, government pays half of the rest and the remainder is added to your total $10,750. Downside is 25 years before forgiveness vs 20 years for PAYE.

The new IDR plan announced increases the interest subsidy to 100% and raises the federal poverty percentage from 150% to 225% for discretionary income. Basically whatever debt you graduate with is the debt you pay + $3000 a year for residency.

If going for loan forgiveness, with $350,000 in principal the break even point where you'd save money with 20 years of minimum payments for loan forgiveness is an annual income of less than ~$260,000. If you made more than $260,000 you'd pay less with the standard 10 year payment plan.

Either way, you're paying back $480,000 whether it's over 10 years @ $3,800 a month or 20 @$2,000 a month.
Now if you only made say, $200,000, monthly payment is $1,500 on PAYE, total paid back is exactly $350,000.

After a certain level of debt, student loans just become a mandatory 20 year, additional 10% income tax which is a little depressing.

 

[Pronation]

When I was an associate at a pod practice in the satellite clinic I was sent to once a week, I had 2 staff, one up front and one MA at the back. I noticed that the MA actually slowed me down. Most of the practice bottle neck is upfront between checking in and checking out patients, answering phone calls, scheduling, faxing referral, insurance authorization etc. Once patient is roomed and I get my chart, it's an express way for me and I am good to go.

Even with 2 front staff, I still sometimes have to wait for the patient to be roomed (due to paperwork, phone calls etc). I recently taught one of my front staff how to take an x-ray and that helped me a lot in moving even quicker. I plan on hiring a 3rd staff soon but I will still want everyone to be trained up front first.

I want every phone call to be answered because that is how I scoop up a lot of new patients looking for same day or same week appointments. Patients call around and they want a live person on the phone, not an auto-machine.

All my back clinic stuff is set up by me and I know where everything is for my procedures from ingrown nail to biopsy to office I&D etc. Casting, DME fitting is all done by me. For booking surgery, I fill out all my pre-op paperwork etc. I do a lot of office procedures and I am very comfortable with no MA at the back. When I was an associate, one of the MA actually told me I am too independent because I don't ask them to get me things, I just go and grab it myself and set things up.

Any associate looking to go solo, you have to be 100% comfortable running the back by yourself. Ideally for a new solo practice, you want to start out with YOU and one staff and grow from there. Helps reduce payroll lol

This sounds incredibly inefficient. I would lose my mind with this type of setup. This sounds like a very old school style of podiatry practice.

As an example, I spend about 10 mins of face to face time with a patient that needs a matrixectomy or a post op flatfoot that needs sutures out and a cast applied. I don’t do sutures, casts, digital blocks, instrument setups, or bandaging. RN and MA run the show.

 

[Feli]

This sounds incredibly inefficient. I would lose my mind with this type of setup. This sounds like a very old school style of podiatry practice.

As an example, I spend about 10 mins of face to face time with a patient that needs a matrixectomy or a post op flatfoot that needs sutures out and a cast applied. I don’t do sutures, casts, digital blocks, instrument setups, or bandaging. RN and MA run the show.

619 can answer for him/herself, but I believe it's just a way of doing office as a startup... to get off the ground and keep overhead low. I would assume MAs are the eventual plan.

I agree that I couldn't do it long term. Some PP docs make it work well for decades and net over $500k solo with few/no MAs and just keeping overhead ultra-low, but I want to see a decent amount of patients and be efficient no matter what type of system I'm in.

I'm pretty surprised you don't do digital blocks, though... seems like those take all of 15sec and MA or even RN would mess them up and miss block, cause ecchymosis, cold spray burn, etc as much as they'd succeed. I do "suture removal" myself too, but I run vicryl + monocryl on basically all elective, so there is almost nothing to do there. I have never been a fan of doling out the procedures (just expecting the setup and cleanup for them)... obvious exception of nail care done by MAs. Callus, verruca, wound, any injects or suture remove are all by me. Casting is one I go back and forth on since so many MA screw it up... but I barely do BK casts in my current setup anyways (CAM for life). That's cool passing those off works for you.

 

[DYK343]

619 can answer for him/herself, but I believe it's just a way of doing office as a startup... to get off the ground and keep overhead low. I would assume MAs are the eventual plan.

I agree that I couldn't do it long term. Some PP docs make it work well for decades and net over $500k solo with few/no MAs and just keeping overhead ultra-low, but I want to see a decent amount of patients and be efficient no matter what type of system I'm in.

I'm pretty surprised you don't do digital blocks, though... seems like those take all of 15sec and MA or even RN would mess them up and miss block, cause ecchymosis, cold spray burn, etc as much as they'd succeed. I do "suture removal" myself too, but I run vicryl + monocryl on basically all elective, so there is almost nothing to do there. I have never been a fan of doling out the procedures (just expecting the setup and cleanup for them)... obvious exception of nail care done by MAs. Callus, verruca, wound, any injects or suture remove are all by me. Casting is one I go back and forth on since so many MA screw it up... but I barely do BK casts in my current setup anyways (CAM for life). That's cool passing those off works for you.

Yeah having someone else do your blocks may ask for legal troubles. My MAs are not allowed to even draw the meds up for me in our clinic. An RN probably could but its 10-15 seconds to give a good block.

I do my own suture removal. Patients are always really nervous for it and they appreciate it when the surgeon does it. takes 20-30 seconds. In grand scheme of things it really doesnt matter and patients like it.

I also remove all my own post op bandages. When I was a resident we had a 2nd HT die with a pin. The MA removed the bandages and the patient sat there for 10ish minutes staring at their dead black toe. After that I refuse anyone else but myself to remove bandages. If there is a problem I dont want the patient sitting there having a panic attack without me there to coach, help, or explain whats going on.

Also bunions, etc are always swollen 1st post op visit and do not necesarily reflect the final correction. I dont like patients to sit there and stare at their swollen foot for x amount of minutes before I can get in the room.

 

[heybrother]

This thread is interesting to me. Some good insights. Partial owner of an established clinic. My partner and I have very different practices. Fun story - I aim to place zero post-op dressings. Put the ace from the surgery center back on and go. Zero casting, boots for all. There's a part of me that finds 619's story interesting in the sense that - I sometimes wonder about things the office is spending money on. If you start your own thing and you question every expense line by line - its assuredly draining but it prevents the bloat from ever forming. My office manager tried to go through the bills line by line during the pandemic but I'm sure there's established things that were just taken as is like our IT company. And we are carrying so much bloat from our overpriced EHR that we can't/won't drop.

I had so much time for going through collections and reviewing my billing/my partner's billing when I wasn't busy. I try to start each day off by getting ready for the patients ie. reviewing follow-ups charts but I also try to check their outstanding balances also. The other day I saw someone who owed $500 and no showed. Left that on my office manager's desk - if we can't collect it in person we'll start calling.

I've had 2 great MAs. One spoke Spanish but had a temper when old men hit on her. The other is funnier/patients love her. Decent mind reading. X-rays before I see the patient, remove sutures, pulled anesthetic shots, steroid shots, dispensed orthotics, knew my educational sheets, set up referrals to cardiology/PT/MRI, room patients, cleaned rooms, ran the autoclave, reprinted educational materials, restocked my rooms, put old people's shoes back on, etc. Apart from essentially following behind me solving problems - they got me out of the room. The longer you are in the there the more the patient remembers something - a nail or callus they wanted trimmed or whatever.

We have 5 employees total for 2 doctors. I've read IPED stories where people discuss that MAs can let you see more patients. I even met a doctor who claimed the MAs wrote his notes for him. But I'm still always a little surprised when I see a 1 doctor practice with an office manager, 3 front desk, and 4-5 MAs in the back. That's a lot of staff to manage, especially if you take a day off. I also suspect there's just a lot of turn-over with that since you can't pay them anything... I suppose if I had that many I'd make them do nailcare but with only 1 MA I don't push that yet.

Last fun thing somewhat in line with the above. Do people in private practice try to collect full fee up front. I've unfortunately had a bit more medical care this past year (snip snip, sleep study, etc). The urologist and the sleep specialist collected full $ the day of service with urology collecting the full price up front. I left that appointment thinking we should take more money from people.

 

[DYK343]

I even met a doctor who claimed the MAs wrote his notes for him.

I was doing this for awhile but found it to take longer than if I just wrote it myself. I wasnt board certified at the time and I was OCD on my documentation for anything surgical. After trying to edit I ended up just deleting theirs and writing my own notes.

Now that im certified I should try it again. If it worked it would save a ton of time. But also have to be careful for legal reasons.

 

[Pronation]

I was doing this for awhile but found it to take longer than if I just wrote it myself. I wasnt board certified at the time and I was OCD on my documentation for anything surgical. After trying to edit I ended up just deleting theirs and writing my own notes.

Now that im certified I should try it again. If it worked it would save a ton of time. But also have to be careful for legal reasons.

You have to create templates for them to click through and ask questions for a multitude of different encounter types otherwise they will write the most garbage HPIs ever. Once you take the time to do this then you'll rarely have to tinker with the HPI for most stuff.

 

[dtrack22]

But I'm still always a little surprised when I see a 1 doctor practice with an office manager, 3 front desk, and 4-5 MAs in the back.

This is why they can’t pay an associate more than 30% of collections. Overhead runs at 60%.

 

[DYK343]

Fun story - I aim to place zero post-op dressings. Put the ace from the surgery center back on and go.

Wait. No gauze? Just an ACE wrap? Curious if any increase in infection (I assume not..)? I would be worried about post op pain from the ace rubbing on sutures.

 

[Boba Foot]

I've unfortunately had a bit more medical care this past year (snip snip, sleep study, etc).

CPAP will change your life. I felt like a dead man for the first 2.5 years of residency. Wish I'd recognized the problem earlier and had the time to address it.

 

[Boba Foot]

Ortho or Cards is basically the best example with the docs basically only popping in to greet and make the plan.... typically very high staffing and high pt volume.

Do you ever get any pushback or poor feedback from your patients for brevity of visits? When I was in my 20's before deciding to go into medicine, I always hated it when docs would pop in for 3 minutes, not really visibly do ****, leave and then charge a specialist's fee. I recognize that I was young and my pathology was always minor in retrospect, but I always couldn't help resenting a doctor when you take time off from work, sit in waiting for 30 minutes, and then see them for 3 minutes for churn and burn.

Obviously, I recognize the monetary logic behind it now that I'm a practitioner and need to churn and burn myself, but how do you toe that fine line without seeming like a jerk to your patients? Recently entering practice, that's sort of what I'm struggling with. It's fine now that I'm relatively slow waiting for all insurance panels to accept me, but once I get busier it's gonna be different story.

 

[Feli]

Do you ever get any pushback or poor feedback from your patients for brevity of visits? When I was in my 20's before deciding to go into medicine, I always hated it when docs would pop in for 3 minutes, not really visibly do ****, leave and then charge a specialist's fee. I recognize that I was young and my pathology was always minor in retrospect, but I always couldn't help resenting a doctor...
...It's fine now that I'm relatively slow waiting for all insurance panels to accept me, but once I get busier it's gonna be different story.

Not at all. It's mostly just personal relationships. I get basically 90% five star, 9% four star. We have a text msg rating system in the EMR, and if they do 5 star, it follows up to ask them to rate on Google (few do, but those are good also).

The key is just giving them value... stay in rapport, full attention, eye contact, take notes on my clipboard of injury or surgery dates, good physical exam, handwritten Rx pad to write terms or OTC Rx (lido, diclof, nystatin powder, etc), handwritten notes on their XR print or educational handout. I never bring ipad in room (but MA does)... Im all about them for my 5-15+min in room. Brief good attention and results trumps mediocre long visit in my exp.

You said it all in what I bolded:
The physical exam can't be underestimated in terms of pt experience and impression; it really builds trust quick (shows interest in their problem, physical touch, should be done systematic for at least a min or two on every new pt even if you saw XR, MRI, know dx from history, etc). COVID sucks, but handshake, fist bump, encourage tap calf/knee, or tap on the shoulder builds rapport if you can. The reviews are really more connection/trust as much as time. Some excellent technical or surgical docs don't have the soft skills, and the bad reviews can damage them. Fwiw, I 'cheat' by putting a personal detail at note start... "34yo new pt active in ballet..." or "80yo f/u pt who enjoys gardening..." or "45yo new pt coaching HS baseball..." or "71yo f/u pt active in yoga... ." It can be whatever, but it definitely makes for convo starter at f/u visits (i encourage MAs to use it too). Every pt has different needs, but they all have things they know about and enjoy.

I print XR always (invert B/W to save ink) to show them I've spent time on them before i walked in. I teach my MAs to make pts feel unique, that their problem is special and plan is at least somewhat unique. In reality, we have everything pretty set to go... injects drawn, ingrown trays prepped, all my surgery before/after ready to print, DME and OTC all ready to go, etc.

It also helps asking them what they do, where they work etc. Some phrases I like...
"What are we helping you with today?"
"You see Dr X for your checkups? She's excellent."
"What are you doing for work or activities?"
"What kind of shoes do you wear most days?"
"So, whats going on this weekend?"
Ask about football, hobbies, local events, etc to find their jam.
"Do you have any other questions?"

Fwiw, we do run a good amount of staff (ratio of roughly 1.5 or 2 MA plus 1.5 or 2 front desk per doc... plus manager on site who can MA or desk... and call center operators, billers, HR, marketing, various corporate trainer and admin ppl, etc at other location). That helps. I can have my MA go get inject, night splint, plantar fasciitis handout while to talk to pt... and MA can Rx NSAID when they get back too. Front desk does PT Rx, work notes, Rx tests, etc. Also, that decent amount of staffing definitely gives the social proof of the doc being important and successful... pts tend to assume the doc is busy and in demand, so they feel lucky to have your time and will be tolerant of less of it - provided wait time and exp and results are good.

I do the procedures myself, dx and imaging discuss and plan, and most post-op as DYK suggested, but I delegate as much as possible to MAs. Again, not saying nobody respects me if I roomed my own, get own supplies, etc... but they'll definitely view me as less busy and more accessible than with the way I do it with trained assists expediting me. I might do a little more of that stuff on a slow day or for new pt or on a day that MA calls in, but in general, MAs like drawing up injects, stocking rooms, learning DME disp, learning ABI, etc... it makes them more valuable and builds their skill (which can build their income).

One occasional efficiency snag is that a few pts will demand the doc do their nail care as they're anxious, but I usually do the cutting nails while we talk at new pt visit, tell them MA will do Dremel and then everything in the future. I do calluses or dx/plan and any legit invasive or procedure, but I don't do much of routine nail care... or I basically get rid of them if they still try to 100% demand it. It might sound mean, but they're the lowest paying and most boring pts anyways with low E&M, usually grumpy ppl if they don't trust my system/judgment, they might be wheelchair/transportation and arriving late or slowing pt flow anyways, and I mainly don't want to treat some different/special just because they're needy with things 95% of other people accept just fine. I am not one of those docs who will 'find' stuff and run a bunch of ABI, "ingrown" procedures, nail "biopsy," tendonotomy, etc on ppl who don't need it and just want nail care... that would depress me, I question the ethics of that, and I have enough sports/tendon/fascia and injury and surgery and wound pts who do actually need proc and things. I aim to set the tone early with the nail pts; I explain to them it's like the dentist where I do the exam and MAs do the routine care. The MAs have done nail care on 70% of new and 95% of f/u nail pts before I walk in. In my exp, being "nice" and making exceptions unfortunately empowers them to demand even more unique treatment on other stuff... will try to wiggle out of copays, free pads/spacers, etc etc (basically play the "I'm old" or "I'm sick" card more and more often). I suppose that it's a personal call based on how busy you are or how much help one has. I only average maybe 3-5 nail care pts out of 25-30 pts on most days' schedule, so it's not a huge deal overall (but I do view spending 15+mins in room versus 5mins for a 99213+11721 as a big deal if it's totally stuff MA can do a good job with).

Also HIGHLY important is that I have close relationships with most PCPs. It takes time and is easier rural/suburban. Nonetheless, they talk me up, so I have a sorta unfair advantage with pts arrive thinking I'm good even before they meet me. I send the PCPs their surgery clearances, have front desk fax key progress notes, call or txt PCP or ER about interesting surgery or inpatients they sent, little holiday gifts, etc. That goodwill is invaluable and really adds to the doc perception by the pts.

I aim for something like this (for new pt):
1min intro, joke or try to get rapport
1min let them talk, just make notes or nod/lead through HPI
2min physical exam and talk
1min talk xray or tests they did/will do
2min talk tx options /handout
1min lead them to tx I think will work
1min explain Rx, DME, etc they're receptive to
1min summary, suggest f/u, get more rapport, close

Thats 10min average me with new pt in room. They also saw MA for 5min before me and another 5min after for DME or OTC or etc. I do the "did we answer all your questions" majority of the time and probably 80% no questions or 10% just ask "when do I come back?" A few have a quick question, complex ones can get a satisfactory answer but told talk more at f/u. That's just what I saw my popular and successful attendings do in residency and my good mentors do since then. I sometimes spend more if I have the time, but most good docs are in high demand - or will be very soon. If I had time for 30min in the room, then I need to go meet many more PCPs with that time!!!

...Notes are another friggin story. A lot of guys in our group have MA do 90-100% of each note. I do more % of my notes than most (fairly tied to that i do more surgery than most). I use templates for common stuff and procedures but unavoidable to type a bit on surgery/complex pts.

I could care less about getting sued (won't get sued much if pts like you... and office easily pays the 1/10,000 suits with time and productivity saved on the other 9999). I chart decent mainly so billers know what I did, so I or partners know what I did when pt f/u, and since I'm finishing ABFAS cases. Notes are lame.

 

[Scrantonicity]

Last fun thing somewhat in line with the above. Do people in private practice try to collect full fee up front. I've unfortunately had a bit more medical care this past year (snip snip, sleep study, etc). The urologist and the sleep specialist collected full $ the day of service with urology collecting the full price up front. I left that appointment thinking we should take more money from people.

Yes, we do...even for surgeries--full amount paid upfront or we reschedule. Only problem is positive balances from time to time, and you have to refund the patient--this doesn't happen very often since deductibles are so high--but when it does the patient is always happy, and writes you a great review!

If we didn't do it this way, we just wouldn't get paid...simple as that.

 

[Pronation]

Yes, we do...even for surgeries--full amount paid upfront or we reschedule. Only problem is positive balances from time to time, and you have to refund the patient--this doesn't happen very often since deductibles are so high--but when it does the patient is always happy, and writes you a great review!

If we didn't do it this way, we just wouldn't get paid...simple as that.

Yup, agree 100%. Cash upfront with commercial insurances for all procedures.

 

[619]

619 can answer for him/herself, but I believe it's just a way of doing office as a startup... to get off the ground and keep overhead low. I would assume MAs are the eventual plan.

I read all the replies and this is the summary of the future plan that I have before everyone jumped on me for not having an MA (saying I am inefficient, old school etc). I opened my practice in 2020 with one staff and 2021 I added another staff and I am currently hiring another staff bringing my total to 3. Next year I will add another staff. I am getting busier and busier and actually seeing my practice grow and revenue increase tremendously (the reason I am hiring). You can't put the cart before the horse and expect to move however I am aware that I don't want to be a gold fish stuck in a bowl that can grow but unable to grow.

I can very much afford and very tempted to hire 2 staff at once currently but I am sticking with my plan of adding one staff each year. It's a marathon not a sprint.

 

[619]

Last fun thing somewhat in line with the above. Do people in private practice try to collect full fee up front. I've unfortunately had a bit more medical care this past year (snip snip, sleep study, etc). The urologist and the sleep specialist collected full $ the day of service with urology collecting the full price up front. I left that appointment thinking we should take more money from people.

Yes. I collect the fees upfront. How do I know how much to collect? We verify each new patient insurance and see what's covered, deductible, co-insurance and verify the co-pay. Then For each insurance, I looked at the EOB and see the allowable so I created a fee schedule (for the most common codes) for the exact amount for each insurance and we collect the amount at check out.

Each new patient, we tell them over the phone that they should bring their co-pay and any deductible, co-insurance etc is due at time of service.

 

[heybrother]

Yes. I collect the fees upfront. How do I know how much to collect? We verify each new patient insurance and see what's covered, deductible, co-insurance and verify the co-pay. Then For each insurance, I looked at the EOB and see the allowable so I created a fee schedule (for the most common codes) for the exact amount for each insurance and we collect the amount at check out.

Each new patient, we tell them over the phone that they should bring their co-pay and any deductible, co-insurance etc is due at time of service.

I have a pretty good idea for every single common insurance what the visit will be worth, but my office doesn't yet have the fortitude to do this. People talk about how doctors shouldn't discuss money, but I tell everyone who presents for nail surgery (and has higher reimbursing insurance) what their worst case number is going to be and patients seem to appreciate it. has good insurance and nail surgery what their worst number is going to be.

 

[heybrother]

CPAP will change your life. I felt like a dead man for the first 2.5 years of residency. Wish I'd recognized the problem earlier and had the time to address it.

Getting acclimatized to a CPAP takes work. I waited 4 months to get mine. The first night I used it - totally broken - it was assisting inhalation when I was exhaling etc. Thought I was going to have a mental breakdown. Never fell asleep. Took it back the next day and they told me it was defective and gave me a new one. Tried using a partial face. Seemed ok but big adjustment keeping my mouth shut. Then the nose piece started to occlude and choke me. Just switched to a full true face mask today. The things I do to stay alive. Meanwhile, I've totally changed my diet, given up alcohol, sugar, soda, all drinks with sugar etc, coffee, 99% of junkfood, etc. I won't turn down guacamole with chips but I can walk past all the cookies/cakes patients bring with ease. Great weight loss because of it but I think I'm stuck with the CPAP forever.