Continuing existential job/life crisis. Any thoughts or insights welcome.

[Fococoroco22]

Hello again.

TLDR: Miami home base with locums travel. Vs Kaiser in LA. 1099 vs golden handcuffs. With taxes and col adjustment Kaiser still wins mainly bcs of pension vested after 10y and up.
Essentially a choice between going back home to Miami where I am familiar vs venture out to LA. Have best friends and history in Miami. Very close Cousins in LA. Extrovert. male, straight, Jewish, still single but ready. Pure logic dictates Kaiser for safety in retirement also “nothing risked/ventured nothing gained” mentality perhaps.
Essentially, I’m not asking for specific advice, though I’m happy for any insights or thoughts you all are willing to give.
What I’m asking for, meditating for, praying for is to figure out what questions I need to ask myself to gain more clarity and certainty.

--------
Leaving current job on good terms. Was a hospitalist for 3+y then concierge for a change, now leaving OP.
Outpatient, even in the desirable realm of concierge medicine, isn’t for me at this time in my career. It is an excellent way, however, to spend the last 5 to 10 years of my career. I wouldn’t say that I’m a masochist, but inpatient/sick patients is where my heart has always been.

I was born and raised in Miami, my three lifelong friends are there, and I am an avid waterman/diver. Currently I live about two hours away, but go every other weekend to spend time with my my father, friends, and the water. It’s as meaningful as a group of your closest friends and your personal passion can be. That said it is still friends and a hobby that drives me back. I have no great love for the city itself but when I’m away either overseas or in other cities or states, I’m pretty regularly overcome with a rather strong sense of home-sickness. It’s been like this since leaving after high school. Can’t explain it, doesn’t make sense necessarily, it just is what it is.

Since handing in my resignation papers with my current concierge practice, I have been offered, thankfully, a number of excellent jobs. One is at a large center in Miami. However, the pay is trash and the census is high with no cap. They used to be great but they were just bought by a corporation and it’s kind of obvious that they’ve turned into a meat grinder. So that’s off the table but I just wanted to share.

The next option for moving back home is locum tenens, I have at least three locations where I’m being credentialed that offer above average pay 190/h to 200 for days 210/h to 215 for nights. Id plan to work about 20 weeks a year.

I’ve also been very grateful to be offered a position with Kaiser inpatient in Southern California. From what I have experienced from multiple interviews and a site visit, they have Excellent Support, low census [12-15 max] , low-ish admin bs and most importantly, a seemingly great and collegial culture and people. They also offer a pension which, if I stay for 10 to 20 years, i.e. what they call the golden handcuffs, will provide pretty significant benefits in retirement. The base pay is also above average even accounting for the higher taxes and cost of living vs Miami. Im behind in my retirement planning fwiw. I dont want to work longer than I have to.

In LA, where my Kaiser site would be, I have my cousins and their families. I’m extremely close to my cousins, we grew up like brothers.
In Miami I have my oldest and closest friends, familiarity, the place I grew up in and my water.

I appreciate the personal, spiritual and professional challenge of totally resetting my life and moving to LA + the long term benefits of the pension. Nothign ventured nothign gained etc.

However, there is something holding me back that I can only describe at this time as "homesickness" whenever I commit in my head to LA. its a LIFE-long decision 10-20y to appreciate the benefits.
I dont love LA. Its a jam packed, overcrowded, dusty dry, mad-maxish dessert. At least to the uninitiated and compared to FL. But I know California has beauty, it just takes more work and time to get to.

Last week I made the decision in my head to go to California--Mainly bcs of the long term value and the growth catalyst of change and starting over. I then proceeded to start waking up essentially in a cold sweat with images and feelings and thoughts of all that I would be missing: Growing old with my lifelong friends, of course we’d always be close but its not the same, at least in my head. I’d also be leaving my natural environment, the water, and any conservation groups and social diving groups that I’m a part of.
There was what felt like real fear there. Or just being lazy and spoiled. IDK. Struggling still.

Essentially, I’m not asking for specific advice, though I’m happy for any insights or thoughts you all are willing to give.

What I’m asking for, meditating for, praying for is to figure out what questions I need to ask myself to gain more clarity and certainty.

Is that relatively clear?

As always, thanks to the members of this board. I don’t know if anyone has been in any situation even remotely close to this, but if someone has, you have my sympathies and my gratitude.

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[gulmohr]

Do you think there's a chance an opportunity similar to Kaiser's will still be available 2 years from now? If no, then I would probably take a shot at it. The locums in Miami will still be there in the future and you can always come back if LA is intolerable.

 

[dozitgetchahi]

There’s a lot going on here, but I’m going to be short and succinct.

Sometimes in life, you just have to dive into something and see how it goes. I’ve been an attending now for about 5 years and I’ve changed jobs 3 times. My wife and I currently live hundreds of miles away from any of our family. Despite all this, we are happier here than we have ever been. However, along the way we misfired several times. We went to the South for a while, which turned out to be a place that was totally wrong for us and which we really disliked. However, we never would have known that if we hadn’t gone.

Also (and I’m not going to go into details here, but still) my wife and I experienced a great deal of personal and family trauma during the pandemic. It was difficult, but it was also wonderfully “clarifying” in many ways. There’s nothing like a series of earth shattering life events to teach you that a lot of anxieties in day to day life are actually surprisingly trivial.

So if you want to go to California, go to California. It’s got a coast. There certainly will be diving groups, conservation groups, and such. Aquatic activities are a big deal there. You will make new friends. And if it doesn’t work out for you, so what? Try again somewhere else. And keep trying until something makes sense for you.

(Also…it’s a big country and I can’t help but think you’re limiting yourself by only considering two cities on the coasts. Look elsewhere too.)

 

[DrMetal]

Outpatient, even in the highly desirable realm of concierge medicine, isn’t for me at this time in my career. It is an excellent way, however, to spend the last 5 to 10 years of my career.

I've always maintained that concierge medicine is BS. No one should have an 'on call' doctor. Do you have an on call accountant, or a lawyer? No, unless you're in financial or legal trouble. Take care of yourself well, and you don't need a doctor to prescribe you Flexeril every time you have a psychosomatic musculoskeletal complaint. This is a stupid First World phenomena.

Since handing in my resignation papers from my current concierge practice, I have been offered, thankfully, a number of excellent jobs. One is at a large center in Miami. However, the pay is trash and the census is high. They used to be great but they were just bought by a corporation and it’s kind of obvious that they’ve turned into a meat grinder. So that’s off the table but I just wanted to share.

This is unfortunately the case in many places. Hospital medicine is kind of a sinking ship. Be careful of the Kaiser. They make a very attractive offer, but those I've talked to ultimately weren't happy there.

All said, go with the Miami option (or something else in Florida). Sounds like you enjoy being close to home. It'll be a lot easier for you to get into your hobbies, stay in that good mental space, and forget about work.

 

[dozitgetchahi]

I've always maintained that concierge medicine is BS. No one should have an 'on call' doctor. Do you have an on call accountant, or a lawyer? No, unless you're in financial or legal trouble. Take care of yourself well, and you don't need a doctor to prescribe you Flexeril every time you have a psychosomatic musculoskeletal complaint. This is a stupid First World phenomena.

I have a DPC PCP and, honestly, it’s one of the best decisions I’ve ever made. I pay about $100/month. The service is great, and I don’t have to poke around trying to get into a regular PCP whenever my family needs health care.

You can feel however you like about it, but my DPC does very well for himself and feels very happy about what he does. I really like the service I get. Win/win. IMO, anything doctors can do to make a living outside of the asinine medical industrial complex that dominates America currently is a good thing.

 

[FlowRate]

Coming here from your psych posting.

FWIW, I like working for Kaiser. But I'm an outpatient psychiatrist in a non-CA region. YMMV.

Are you someone who makes friends in adulthood easily or have you not felt the need to do so since you've been near enough to your life-long close friends?

Are there really no other options in/near Miami or are you just hurting for something NOW rather than waiting a bit longer?

 

[DrMetal]

I have a DPC PCP and, honestly, it’s one of the best decisions I’ve ever made. I pay about $100/month. The service is great, and I don’t have to poke around trying to get into a regular PCP whenever my family needs health care.

You can feel however you like about it, but my DPC does very well for himself and feels very happy about what he does. I really like the service I get. Win/win. IMO, anything doctors can do to make a living outside of the asinine medical industrial complex that dominates America currently is a good thing.

I'd argue that you're wasting your money. Most primary care appointments can be booked routinely (you don't need to see your doctor today, for your annual physical), and many clinics offer same day appointments (perhaps not with your own physician) for urgent needs. Beyond that, any dire emergencies can be handled by your local ER (should be seldomly used).

If you're relatively healthy, that's all you need. You don't need a doctor on standby.

Now, if you insist on it, and wanna pay the money, go nuts. But that's mostly a psychological need, not a true medical one.

You can also pay me $50/month for my glorious, insightful and witty posts here on SDN (I take Venmo).

 

[chessknt]

The tax and CoL situation is going to be vastly different for LA vs. Miami so that should be considered. Also it is dramatic to say your relationship is 'sacrificed' because you wont live near your friends. I have friends like yours dating back to high school/college and I havent lived near them (ie a 6 hour+ plane ride away) for over 10 years--I check in every few months and make an effort to visit them once every year or so and sometimes they come to visit me. We have phones and the internet--it isn't covered wagon times where the postal service was the only form of communication.

 

[Splenda88]

Do you have to live in Miami?

Can you get a job in Palm Beach County and live in Broward County (eg., Pompano Beach), so you can be halfway in-between Miami and your job... When I was looking for jobs 2+ years ago, the job offers in Palm Beach were better than the one job offer I had in Miami.

30 minutes to get to your job and 30 minutes to get to Miami is not that bad in my opinion.

 

[dozitgetchahi]

I'd argue that you're wasting your money. Most primary care appointments can be booked routinely (you don't need to see your doctor today, for your annual physical), and many clinics offer same day appointments (perhaps not with your own physician) for urgent needs. Beyond that, any dire emergencies can be handled by your local ER (should be seldomly used).

If you're relatively healthy, that's all you need. You don't need a doctor on standby.

Now, if you insist on it, and wanna pay the money, go nuts. But that's mostly a psychological need, not a true medical one.

You can also pay me $50/month for my glorious, insightful and witty posts here on SDN (I take Venmo).

Again, I disagree with you on virtually every point. It works very well for my family and I for less than the cost of some types of co-pays for our insurance. It’s some of the best money I’ve ever spent in terms of healthcare.

Also, I work at the kind of institution whose insurance requires you to use the institution’s own providers. At my last job, I saw how incredibly porous “patient privacy” was when the institution’s own doctors were using other doctors in the same practice. No thanks. I have no desire to get my healthcare at the same place I work. I don’t want my family’s health issues to be the talk of the town. And I am not the only doc who feels this way.

 

[chessknt]

Again, I disagree with you on virtually every point. It works very well for my family and I for less than the cost of some types of co-pays for our insurance. It’s some of the best money I’ve ever spent in terms of healthcare.

Also, I work at the kind of institution whose insurance requires you to use the institution’s own providers. At my last job, I saw how incredibly porous “patient privacy” was when the institution’s own doctors were using other doctors in the same practice. No thanks. I have no desire to get my healthcare at the same place I work. I don’t want my family’s health issues to be the talk of the town. And I am not the only doc who feels this way.

I mean the psych component as mentioned seems to apply here... I have received healthcare from my colleagues before and never once worried that I was the 'talk of the town' unless you worked at a super ****ty place I have never spoken about a colleague's health situation unless they brought it up. People get terminated for way less than that.

 

[NewYorkDoctors]

I'd argue that you're wasting your money. Most primary care appointments can be booked routinely (you don't need to see your doctor today, for your annual physical), and many clinics offer same day appointments (perhaps not with your own physician) for urgent needs. Beyond that, any dire emergencies can be handled by your local ER (should be seldomly used).

If you're relatively healthy, that's all you need. You don't need a doctor on standby.

Now, if you insist on it, and wanna pay the money, go nuts. But that's mostly a psychological need, not a true medical one.

You can also pay me $50/month for my glorious, insightful and witty posts here on SDN (I take Venmo).

agreed on every point. (except paying you on Venmo)

Although I do not do DPC, I have some very very needy patients. I take care of most of their issues via email or a phone call.
honestly, it's exhausting answering emails at all times of the night. but I get it done for these "special patients." these patients are mainly the "legacy" primary care patients I saw before I specialized.
on the other hand, this helps me get the care needed to some of the legitimately neediest patients. I am seeing a young mid 20s person with metastatic colon cancer on fourth line Lonsurf and developing drug related ILD (likely). We have only had two in office visits (doing all the required pulmonary procedures under the sun) but many phone calls and emails in between to set up oxygen, review home pulse oximetry, coordinate thoracic surgery evaluation, do palliative care discussions, discuss concerns about using opioids for dyspnea and cough relief, talk pros and cons for corticosteroid use before the biopsy, etc... i'd like to think I helped this poor patient develop some degree of symptom relief without having to be admitted to the hospital. Moreover, it would be impossible to have this degree of discussion in the office visit without cutting into other patient time.

why do I give so much access to myself like this? I like to reserve my in office time for high RVU / high CPT code visits. If I'm not using a lot of CPT codes with the office visit -25 modifier (legitimately of course - the insurances have asked for documentation many times. once I provide it all they approve and pay me) then it is not worth it. I cannot burn office time seeing psychosomatic complaints, just chatting about something they read on social media, or just "doing a med refill."

Most of the patient population I see are Medicaid or Managed Medicaid, or Medi/Medi which means they have zero deductible and zero copay (and are not capitation). This means they pay nothing for every doctor's visit.

While an Internist would love to keep seeing and billing (and the patient would like it to), I cannot burn my office time on a single 99213 like that.

But the point remains, most of these "concierge" type of complaints are just the patient wanting to shoot the breeze with the friendly family physician like Captain Kirk talking to good old Dr Leonard Bones McCoy. who is Spock getting in the way of the fun? probably CMS.




anyway we seem to have hijacked the OP's thread

Last week I made the decision in my head to go to California--Mainly bcs of the long term value and the growth catalyst of change and starting over. I then proceeded to start waking up essentially in a cold sweat with images and feelings and thoughts of all that I would be missing: Growing old with my lifelong friends, of course we’d always be close but its not the same, at least in my head. I’d also be leaving my natural environment, the water, and any conservation groups and social diving groups that I’m a part of.
There was what felt like real fear there. Or just being lazy and spoiled. IDK. Struggling still.

Don't feel lazy and spoiled. You need to do what is right for you.
Seems like your priorities are quality of life and taking care of your happiness first and foremost (rather than pursuing top dollar as a physician). You can't go wrong moving to California. Politics aside, it's still a beautiful place (outside of the cities).

Also if you like inpatient medicine but do not want to be a meat grinder in a corporate setting, have you considered academic internal medicine faculty for an IM residency program? Of course you probably wont get half the year off with that job. but at least it is something steady

 

[DrMetal]

Also, I work at the kind of institution whose insurance requires you to use the institution’s own providers. At my last job, I saw how incredibly porous “patient privacy” was when the institution’s own doctors were using other doctors in the same practice. No thanks.

Well I'm certainly not suggesting that's ok. Sounds like you need to find yourself a new 'institution'.

All I'm saying, is that in most well-constructed primary care offices, you have plenty of access to care, if you're reasonable and know how to navigate the system [for instance, don't be the a-hole patient that insists on only seeing his doctor for an urgent same day appointment, an ankle sprain that any available doctor can easily manage.]

Look, I don't fault you. $100/month is nothing. I spend twice that on whiskey, and three times as much on golf.

I'm just against the concept of it, in general. Too much babying going on in medicine right now.

 

[FlowRate]

Well I'm certainly not suggesting that's ok. Sounds like you need to find yourself a new 'institution'.

All I'm saying, is that in most well-constructed primary care offices, you have plenty of access to care, if you're reasonable and know how to navigate the system [for instance, don't be the a-hole patient that insists on only seeing his doctor for an urgent same day appointment, an ankle sprain that any available doctor can easily manage.]

Look, I don't fault you. $100/month is nothing. I spend twice that on whiskey, and three times as much on golf.

I'm just against the concept of it, in general. Too much babying going on in medicine right now.

I agree with a large part of the point you're making--if you're already an established patient at a good PCP's office then DPC is unnecessary.

But good luck, in some parts of the country, actually becoming an established patient of a good PCP's office in the first place. In those situations, I can certainly see DPC being a shortcut to getting care now rather than significant amounts of time either waiting for an intake or searching for decent open practices.

 

[dozitgetchahi]

agreed on every point. (except paying you on Venmo)

Although I do not do DPC, I have some very very needy patients. I take care of most of their issues via email or a phone call.
honestly, it's exhausting answering emails at all times of the night. but I get it done for these "special patients." these patients are mainly the "legacy" primary care patients I saw before I specialized.
on the other hand, this helps me get the care needed to some of the legitimately neediest patients. I am seeing a young mid 20s person with metastatic colon cancer on fourth line Lonsurf and developing drug related ILD (likely). We have only had two in office visits (doing all the required pulmonary procedures under the sun) but many phone calls and emails in between to set up oxygen, review home pulse oximetry, coordinate thoracic surgery evaluation, do palliative care discussions, discuss concerns about using opioids for dyspnea and cough relief, talk pros and cons for corticosteroid use before the biopsy, etc... i'd like to think I helped this poor patient develop some degree of symptom relief without having to be admitted to the hospital. Moreover, it would be impossible to have this degree of discussion in the office visit without cutting into other patient time.

why do I give so much access to myself like this? I like to reserve my in office time for high RVU / high CPT code visits. If I'm not using a lot of CPT codes with the office visit -25 modifier (legitimately of course - the insurances have asked for documentation many times. once I provide it all they approve and pay me) then it is not worth it. I cannot burn office time seeing psychosomatic complaints, just chatting about something they read on social media, or just "doing a med refill."

Most of the patient population I see are Medicaid or Managed Medicaid, or Medi/Medi which means they have zero deductible and zero copay (and are not capitation). This means they pay nothing for every doctor's visit.

While an Internist would love to keep seeing and billing (and the patient would like it to), I cannot burn my office time on a single 99213 like that.

But the point remains, most of these "concierge" type of complaints are just the patient wanting to shoot the breeze with the friendly family physician like Captain Kirk talking to good old Dr Leonard Bones McCoy. who is Spock getting in the way of the fun? probably CMS.




anyway we seem to have hijacked the OP's thread



Don't feel lazy and spoiled. You need to do what is right for you.
Seems like your priorities are quality of life and taking care of your happiness first and foremost (rather than pursuing top dollar as a physician). You can't go wrong moving to California. Politics aside, it's still a beautiful place (outside of the cities).

Also if you like inpatient medicine but do not want to be a meat grinder in a corporate setting, have you considered academic internal medicine faculty for an IM residency program? Of course you probably wont get half the year off with that job. but at least it is something steady

Most PCPs aren’t like you - they’re generally horrible when it comes to patient access. I don’t want to wait weeks for my family to wait to get in to see my own doctor for some acute issue. If I want to see my DPC doc today, I can - without question. That’s virtually never been the case with any traditional PCP I’ve had in the past.

DPC care works for me and my family and I’m going to continue using it. It’s actually pretty cheap, all told. I also like supporting doctors outside of the insurance racket that currently dominates American medicine today. I’m really surprised to see all the pushback about it here - in fact, most doctors in my area seem to use it. My DPC is much happier than he was before he stopped taking insurance. Personally I’d rather see a happy, satisfied professional who can spend time with you rather than rushing you out of the exam room in 10 minutes because he’s got 30 other patients on the schedule today. Y’all can do what works for you. I’m going to continue to use what works for me.

 

[dozitgetchahi]

I agree with a large part of the point you're making--if you're already an established patient at a good PCP's office then DPC is unnecessary.

But good luck, in some parts of the country, actually becoming an established patient of a good PCP's office in the first place. In those situations, I can certainly see DPC being a shortcut to getting care now rather than significant amounts of time either waiting for an intake or searching for decent open practices.

This has been a problem also, in my experience. Also, while there may be PCPs available in any given area, there is no guarantee that many (or any) of them are “good”.

Come to rural flyover country where I live and work and see what passes for “medical care”. I wouldn’t send my goldfish to the majority of the doctors in my area. When I lived in the South previously, this was the case also. In both situations, I have used DPC doctors because they were generally much better than the prevailing quality of most other available care.

 

[Osteoth]

Are you sure about Kaiser? Have heard they’re quite the meat grinder themselves. Is days/nights outlined in your contract, as well as number of days a month?