Daily reminder to do the bare minimum

Panacea Financial Contract Review
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I agree it's naïve to think an SDG couldn't lose its contract. People hear horror stories of contracts being lost and errantly jump to the conclusion though that you should never join an SDG because it could happen to you. There is a risk of potentially losing income during a prepartnership period if the contract is lost. However, there is a much greater loss of income by not being paid what you are worth. This is most easily achieved by being a partner in a SDG.

The risk was very much there and real when I joined a SDG as a prepartner solely with the assurances of a prior residency alumn that the job was really good and paid very well. I made less than $150/hour on a pre-partnership track period that took less than 3 years. I received reasonable assurance along the way that I would make partner. Upon making partner, my income increased as privately advertised and expected. Since that time our group has continued to maintain the contract very deftly while other groups have not had similar success. We are now in an era where CMGs and PE are struggling. EPs more frequently discuss reclaiming ownership. I have no illusions regarding the challenges of EM and the cons of the field. Yet I was fortunate enough to find a path that feels quasi-sustainable and has prevented me from pursuing a fellowship or a way out. The more likely end of my career and journey in EM is through financial independence even if I don't retire as early as I once suspected. The only way this was possible was due to the SDG I joined.

Some are skeptical of SDGs because of the stories they have heard regarding losing contracts or of a malignant, predatory group. I certainly may not be able to convince you otherwise. This is the sole reason I gravitated towards discussing compensation because money talks and may be the only way to change minds. We can all look for side gigs and try to maximize investing as much as possible. However, the most significant impact on your financial picture relates to how much you work clinically in EM and how you are paid for those hours worked. The second biggest influence involves how much money you spend taking away from compounded savings and investments over time. All the other factors contribute much less significantly.

I do not know if the MGMA salary numbers presented by BoardingDoc truly reflect EM compensation or not. I do know that in my SGD every year I have consistently made more than the 90th percentile number listed above.

Average of 1,560 hours worked per year. Median of $360,771 per MGMA numbers listed above puts average hourly at $231. In comparison, 90th percentile at $468,342 equates to $300/hour. Much fairer. $150/patient at 2 pph = $300/hour. Difference of $108K/year. Multiply that by 10-20 years and that is a decent amount of money you are either gaining or leaving on the table. You can also make quite a bit more than $468K/year. I make more than that amount. I also work more than 1,560 hours/year, but my average hourly is also higher than $300/hour. It's not about income bragging rights. It's about empowering others to know their value and find positions that reflect their worth.

Working for a SDG is not a right and does not necessarily come on a silver platter. It takes work and commitment to maintain a contract. It is work that all of us as partners have put in. We were not the first to do it. We stand on the shoulders of those that did it before us. The reward was worth the sacrifice of sweat equity and a buy-in. I did not deserve immediate partnership just because that is seemingly more fair. Others put in a ton of work before I even arrived. I have also now put in the work and added additional value to our group through my contributions clinically and in other areas. I want my current and future partners to have similar commitment. They also have to take that same risk that I once took. I think they will find that the risk is worth the reward.

It isn't my responsibility to mold newer EPs an exact way. Several of my partners are very different from myself. We practice medicine differently. We do have the luxury of that freedom. Medical school and residency is primarily where you learn medicine. However, you truly learn the practice of medicine during your first year out as an attending when no one is constantly looking over your shoulder. You then peak around 5 years of practice. if you join a bad environment, such as working for HCA or a CMG, when you first start out you are sometimes put into a culture that is overly beholden to metrics and individualistic with the philosophy of doing the bare minimum. I want partners that embody the current culture we have in our group. It's occasionally harder to take bad habits out of an experienced attending rather than just start fresh with someone new. We will not maintain our SDG, contract, income and unique practice of EM with bad apples. I also readily admit that there are plenty of amazing, experienced attendings out there that could step in right away in our group as solid additions. Some EPs are better day 1 as an attending without any experience compared to others who have been practicing for a while. Bad work ethic combined with lower intelligence, poor education, poor training and experience in a bad culture makes for a worse EP. There is lots of variability in skill out there. We just have had better luck starting from the beginning. I don't think we are necessarily a unicorn, but do think I have a pretty good job. I will fight to protect and defend what we do have. I hope to convince others to seek what I have found.

Do you want to be an employee that does the bare minimum? Or do you want to be an owner that might work harder, but reaps more reward. Physicians have become employed more and more over the last 20 years with physician autonomy decimated. We are more than employees in my opinion and need to lead health care in a better direction. Daily reminder to do more. You mostly regret what you don't do.
 
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Mount Asclepius said:
I agree it's naïve to think an SDG couldn't lose its contract. People hear horror stories of contracts being lost and errantly jump to the conclusion though that you should never join an SDG because it could happen to you. There is a risk of potentially losing income during a prepartnership period if the contract is lost. However, there is a much greater loss of income by not being paid what you are worth. This is most easily achieved by being a partner in a SDG.

The risk was very much there and real when I joined a SDG as a prepartner solely with the assurances of a prior residency alumn that the job was really good and paid very well. I made less than $150/hour on a pre-partnership track period that took less than 3 years. I received reasonable assurance along the way that I would make partner. Upon making partner, my income increased as privately advertised and expected. Since that time our group has continued to maintain the contract very deftly while other groups have not had similar success. We are now in an era where CMGs and PE are struggling. EPs more frequently discuss reclaiming ownership. I have no illusions regarding the challenges of EM and the cons of the field. Yet I was fortunate enough to find a path that feels quasi-sustainable and has prevented me from pursuing a fellowship or a way out. The more likely end of my career and journey in EM is through financial independence even if I don't retire as early as I once suspected. The only way this was possible was due to the SDG I joined.

Some are skeptical of SDGs because of the stories they have heard regarding losing contracts or of a malignant, predatory group. I certainly may not be able to convince you otherwise. This is the sole reason I gravitated towards discussing compensation because money talks and may be the only way to change minds. We can all look for side gigs and try to maximize investing as much as possible. However, the most significant impact on your financial picture relates to how much you work clinically in EM and how you are paid for those hours worked. The second biggest influence involves how much money you spend taking away from compounded savings and investments over time. All the other factors contribute much less significantly.

I do not know if the MGMA salary numbers presented by BoardingDoc truly reflect EM compensation or not. I do know that in my SGD every year I have consistently made more than the 90th percentile number listed above.

110 hours/month at $270/hour = $363K/year (median listed above). Working 110 hours/month for a SDG at $350/hour = $470K/year (just above the 90th percentile amount listed above). Difference of $107K/year. Multiply that by 10-20 years and that is a decent amount of money you are either gaining or leaving on the table. You can also make quite a bit more than $470K/year. I make more than that amount. I also work more than 110 hours/month. It's not about income bragging rights. It's about empowering others to know their value and find positions that reflect their worth.

Working for a SDG is not a right and does not necessarily come on a silver platter. It takes work and commitment to maintain a contract. It is work that all of us as partners have put in. We were not the first to do it. We stand on the shoulders of those that did it before us. The reward was worth the sacrifice of sweat equity and a buy-in. I did not deserve immediate partnership just because that is seemingly more fair. Others put in a ton of work before I even arrived. I have also now put in the work and added additional value to our group through my contributions clinically and in other areas. I want my current and future partners to have similar commitment. They also have to take that same risk that I once took. I think they will find that the risk is worth the reward.

It isn't my responsibility to mold newer EPs an exact way. Several of my partners are very different from myself. We practice medicine differently. We do have the luxury of that freedom. Medical school and residency is primarily where you learn medicine. However, you truly learn the practice of medicine during your first year out as an attending when no one is constantly looking over your shoulder. You then peak around 5 years of practice. if you join a bad environment, such as working for HCA or a CMG, when you first start out you are sometimes put into a culture that is overly beholden to metrics and individualistic with the philosophy of doing the bare minimum. I want partners that embody the current culture we have in our group. It's occasionally harder to take bad habits out of an experienced attending rather than just start fresh with someone new. We will not maintain our SDG, contract, income and unique practice of EM with bad apples. I also readily admit that there are plenty of amazing, experienced attendings out there that could step in right away in our group as solid additions. Some EPs are better day 1 as an attending without any experience compared to others who have been practicing for a while. Bad work ethic combined with lower intelligence, poor education, poor training and experience in a bad culture makes for a worse EP. There is lots of variability in skill out there. We just have had better luck starting from the beginning. I don't think we are necessarily a unicorn, but do think I have a pretty good job. I will fight to protect and defend what we do have. I hope to convince others to seek what I have found.

Do you want to be an employee that does the bare minimum? Or do you want to be an owner that might work harder, but reaps more reward. Physicians have become employed more and more over the last 20 years with physician autonomy decimated. We are more than employees in my opinion and need to lead health care in a better direction. Daily reminder to do more. You mostly regret what you don't do.
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Agree. In an SDG environment, everyone should go above and beyond. I still maintain though that in a CMG/employed job, there is no reason to.

With regards to the SDG question, why should an experienced attending accept 2 years of low pay, nights, bad scheduling, metrics whipping? This particular SDG has lost at least 3 people that I know of in the past year. In addition there are retired legacy partners who still earn profit sharing.

So it's acceptable for me to fund someone's retirement at 170/hr? That my friend, is predatory.
 
A big downside of EM is that even your ownership is just contingent on the CEO instead of a private practice in psych or ortho

Also you can’t do an hour to hour comparison as a partner in a SDG since you also need to do non clinical things and go to meetings

You also have to hire and fire
 
GonnaBeADoc2222 said:
Agree. In an SDG environment, everyone should go above and beyond. I still maintain though that in a CMG/employed job, there is no reason to.

With regards to the SDG question, why should an experienced attending accept 2 years of low pay, nights, bad scheduling, metrics whipping? This particular SDG has lost at least 3 people that I know of in the past year. In addition there are retired legacy partners who still earn profit sharing.

So it's acceptable for me to fund someone's retirement at 170/hr? That my friend, is predatory.
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That is why SDGs are a better model. They incentivize you better.

I’m not arguing that every SDG out there is good. It’s unfortunate. You have to do your homework. It’s worth trying to find one that is good though. Once you do it beats the alternative hands down.
 
Brigade4Radiant said:
Also you can’t do an hour to hour comparison as a partner in a SDG since you also need to do non clinical things and go to meetings
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We pay for admin time at the same rate as our pre-partner rate. I recognize it does just come out of our own income. However, those that put in more time get a little more. Those that don’t want to do as much administratively lose out on some income. It’s not that much in the grand scheme of things since it is a lower hourly rate and people have much fewer administrative hours compared to clinical hours. Helps you feel like your administrative time is compensated though and a fairly decent system.
 
Mount Asclepius said:
That is why SDGs are a better model. They incentivize you better.

I’m not arguing that every SDG out there is good. It’s unfortunate. You have to do your homework. It’s worth trying to find one that is good though. Once you do it beats the alternative hands down.
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I think most of us would like to work for an SDG as you describe. We're all naturally hard workers who enjoy having control of our environments.

Moving isn't an option for many people. If I moved, I would not see my child.

For those of us in CMG / hospital employed land, the bare minimum is a survival mechanism, as we do not get paid for staying after shift or for admin tasks.
 
GonnaBeADoc2222 said:
Please don't gaslight us by saying a fresh grad is more productive than someone 5 to 8 years out. Everyone knows it take 1 to 2 years to hit yout stride as an attending and around 5 years out you are at your prime.
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Gaslight? Please. Maybe 1-2 years to hit your stride as in feel comfortable but not necessarily regarding productivity. Over the last few years we have had several new residents consistently outperform seasoned attendings with regards to productivity (patients per hour, RVUs per patient, RVUs per hour, etc.). They also didn't have the mindset to do the bare minimum so maybe that's where you went wrong. Maybe it's just us being selective on who gets hired.
 
GonnaBeADoc2222 said:
Agree. In an SDG environment, everyone should go above and beyond. I still maintain though that in a CMG/employed job, there is no reason to.

With regards to the SDG question, why should an experienced attending accept 2 years of low pay, nights, bad scheduling, metrics whipping? This particular SDG has lost at least 3 people that I know of in the past year. In addition there are retired legacy partners who still earn profit sharing.

So it's acceptable for me to fund someone's retirement at 170/hr? That my friend, is predatory.
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It sounds like whatever experience you had with an SDG wasn't a good one. A partnership track with almost always have to work more hours than the partners but the scheduling should still be consistent. Maybe you have to work an average of 0.5 nights/month more just because of the extra hours but there should no difference in the rest of the schedule.

An experienced attending doesn't necessarily have any more of a right for a different partnership track than a new resident. It probably doesn't make sense for a late career attending to do it. It probably makes sense for a mid career attending to do it but my experience is that most people spend so much that it isn't possible.
 
JacobMcCandles said:
Gaslight? Please. Maybe 1-2 years to hit your stride as in feel comfortable but not necessarily regarding productivity. Over the last few years we have had several new residents consistently outperform seasoned attendings with regards to productivity (patients per hour, RVUs per patient, RVUs per hour, etc.). They also didn't have the mindset to do the bare minimum so maybe that's where you went wrong. Maybe it's just us being selective on who gets hired.
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Right so preferentially hire new grads over experience who dont know their worth yet and will accept such conditions. Predatory.

JacobMcCandles said:
Gaslight? Please. Maybe 1-2 years to hit your stride as in feel comfortable but not necessarily regarding productivity. Over the last few years we have had several new residents consistently outperform seasoned attendings with regards to productivity (patients per hour, RVUs per patient, RVUs per hour, etc.). They also didn't have the mindset to do the bare minimum so maybe that's where you went wrong. Maybe it's just us being selective on who gets hired.
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Productivity doesnt equal good care.
 
GonnaBeADoc2222 said:
Right so preferentially hire new grads over experience who dont know their worth yet and will accept such conditions. Predatory.



Productivity doesnt equal good care.
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No, hire the best candidate that is out there. Many times that is going to be a new grad. The last 2 hires that didn't work out in our group were both mid-career docs.

If they didn't give good care then they would no longer be employed by our group.

It's clear that you enjoy doing the bare minimum while being a complainer at the maximum. I suspect that there probably isn't a realistic job out there in EM that you'd be happy with as you'd always find something to complain about without providing solutions. I do hope you find a job you enjoy or at least tolerate.
 
GonnaBeADoc2222 said:
Productivity doesnt equal good care.
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This is obviously true, however, I can tell you that there is a certain standard of productivity that we expect from all of our docs (as would most employers I suspect). We have a conversation with people who don't meet it. If things subsequently fail to improve, they are let go.

FWIW: this is for the sake of maintaining flow in the dept. I don't make any money off of the other docs in the group. We are entirely keep what you kill. There is no "partner" status in our group where someone makes money off of someone else.
 
JacobMcCandles said:
No, hire the best candidate that is out there. Many times that is going to be a new grad. The last 2 hires that didn't work out in our group were both mid-career docs.

If they didn't give good care then they would no longer be employed by our group.

It's clear that you enjoy doing the bare minimum while being a complainer at the maximum. I suspect that there probably isn't a realistic job out there in EM that you'd be happy with as you'd always find something to complain about. I do hope you find a job you enjoy or at least tolerate.
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I tolerate my job just fine. I know my worth, take good care of my patients, and don't allow corporations to exploit me.

Personal insults aside, do you refund the difference between the rate you pay your prepartners and the MGMA average if you decide halfway through their partnership track that you don't like them, or is this just kept and distributed to the partners?

Are there any contractual financial protections for prepartners if you decide to sell or lose the contract?

The argument of "new grads are often more productive" supports my predation argument as these docs are fresh out of the brainwashing meat grinder of residency and you know they will pick up that new patient the second they arrive. Perfectly fine strategy from a business perspective.

If quality was a goal, you'd target docs w moderate experience, who are more than comfortable doing all their own procedures and dispositions solo without any help, and pay for that experience.
 
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BoardingDoc said:
I know it's tomato tomato, but are you really putting an EJ in someone these days and not an US guided PIV? I haven't placed an EJ in years.

And before this starts another side discussion on US PIVs, yes I know this can get abused by nursing if you don't make it painful for them to ask you. If 3 different RNs stick the patient and can't get access I'll do an US PIV. Whether or not others think that's reasonable for them is certainly open to debate.
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Best of both worlds: ultrasound guided IJ (just need the longer angiocath)
 
Sad threat overall. To each their own. Those who know me on here and not know I value the SDG system. There is no way to make it perfect.

Every group has outside issues, money losing hospitals they staff, greedy senior partners, declining reimbursement etc.

My thoughts at the 30k view is this. At an SDG your income is based solely on how well you run your business, you keep profits and the glut of docs and noctors wont impact your income. That is real, that is coming and it wont be pretty.

CMG pay is based 100% of supply demand economics. Its why USACS and other crappy cmgs have replaced docs. As they can hire easier, their debt burden becomes unbearable the only solution is to cut your pay which has happened in many parts of the country. Near me one large CMG just cut pay 30%.

Another one cut pay from 230/hr to 200.

Every SDG is also prone to this but they can choose which levers to pull to protect income/quality of work.

FWIW most SDGs are making over 300/hr based on people i know. Some making substantially more. That discrepancy is big and likely to grow.

Yes hospitals can yank your contract on a whim, thats why the "subsidy" is the noose slowly killing you especially in this time where hospitals are struggling financially as well.

If each person is happy in their situation be it, sdg, cmg employed good for you.

I think for some people it is better to not know how others are doing. there are EM docs making well north of 600/700k if you make 400k and are happy that might not be something you want to know.
Some folks will tell themselves those guys must be cheating, those guys must be overusing MLPs, those guys are committing fraud, those guys must be seeing 5 pph to earn that.. some are... many arent.
 
GonnaBeADoc2222 said:
I tolerate my job just fine. I know my worth, take good care of my patients, and don't allow corporations to exploit me.

Personal insults aside, do you refund the difference between the rate you pay your prepartners and the MGMA average if you decide halfway through their partnership track that you don't like them, or is this just kept and distributed to the partners?

Are there any contractual financial protections for prepartners if you decide to sell or lose the contract?

The argument of "new grads are often more productive" supports my predation argument as these docs are fresh out of the brainwashing meat grinder of residency and you know they will pick up that new patient the second they arrive. Perfectly fine strategy from a business perspective.

If quality was a goal, you'd target docs w moderate experience, who are more than comfortable doing all their own procedures and dispositions solo without any help, and pay for that experience.
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Its interesting on one of the job boards some guy posted for new grads pay was like 200/hr but 230 if ABEM. The younger docs (I presume) said hey we bill the same, insurance pays the same why the difference. I get where you are coming from but i see both sides.
 
EctopicFetus said:
Thats my go to. quick easy and has few issues.
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Plus in everyone, except for the most dehydrated of nursing home mummies, you are aiming for a friggen pipe of a target. I happen to be very good at U/S everything, but its nice to have an incredibly easy time with it even if you could have theoretically threaded the tiny vessel barely larger than the 20g youre using.
 
Another Pro-Tip: Never waste your time completing the "HealthStream" modules or other such BS online learning until threatened by your direct supervisor.
 
EctopicFetus said:
Its interesting on one of the job boards some guy posted for new grads pay was like 200/hr but 230 if ABEM. The younger docs (I presume) said hey we bill the same, insurance pays the same why the difference. I get where you are coming from but i see both sides.
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Definitely.

I think the truly egalitarian system is 100% RVU, eat what you kill.
 
emperor tamarin said:
Give us some stories of how
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This is a life mentality and not just work. There are always easier ways to do anything. Just sit back, clear your mind, and think of solutions. Many tend to wallow in the situation rather than try to fix it. Sometimes situations just can't be fixed no matter what so the choice becomes either to accept/move on or wallow in "woes me".

Just some examples from work
1. We were a SDG who had the DOS based meditech EMR. This is by far the worse and its all typing. I can type super fast but found that my days were miserable acting like a secretary. So I created about 100 templates that covered 99.9% of charts. I was going to type it anyhow, so I just typed it into an online storaged, copied and pasted after changing a few details. I averaged a completed chart in 2 minutes while other docs took about 7 minutes. 5x20ppd = 100 minutes. That is 100 minutes for me to make money, go drink coffee, leave the ER, surf the internet, etc. No one ever complained b/c I was a top 2 RVU producer and went home right on the dot 90% of the time. The other guy who was a top RVU producer stayed 1-3 hrs ever shift. In the long run, this messes with your mind and one reason why I never got burned out even after 15 yrs. Simple fix, and some docs copied me after I explained to them what to do. Others kept being a secretary. I almost never had a down chart either b/c my charts read like a novel.

2. Our specialist/hospitalists became super busy and the slow ones sometimes would take 1-2 hrs to call back. Docs would page, wait after their shift ended to leave bc they rightfully so didn't want to pass this on to the next doc. After a few times of this, I left my cell with the clerk/txt the hospitalists to call me b/c I am going home. No one ever complained and I saved myself countless days of staying back. An 8 hr shift vs a 10 hrs shift is a huge deal.

I can go on and on but I learned to "game" the system and was by far the most efficient doc in our group. When I started to do locums, I again became the most efficient doc regardless of EMR/environment. Nurses loved when I worked b/c I got people out which allows me great latitude to take a bunch of breaks, stop seeing pts 2 hrs before my shift ended, surf the internet. When you are the fastest/most efficient doc, no one cares what you do or leave the ER. Be the slowest doc and they will give you the evil eye if you leave the department.

I can go on and on but I see this in life all the time. The amount of time people take to do simple tasks astounds me. I go in and out, and ever extra minute I save is a minute I can go take a nap or be with my family. Learn this early and work/life frustrations will almost disappear.
 
Siggy said:
...except someone has to cover the slow shifts as well. How's your volume at 4AM? What incentive is there to take a slow antisocial shift?
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It's easy, set a floor, below which no one can go. If the average is $300/hr for the busy daytime shifts, make a slower shift $250/hr plus any night differential depending on difficulty
Brigade4Radiant said:
Nope a hospital must have an ER physician on hospital grounds and if you don't you are not a hospital. You also sign ekgs and get calls from EMS. pure RVU is crazy
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Agreed, night shifts should have a floor or minimum. In most places (admittedly only a few) the night shift doctors on average make more with guarantees and night shift differentials.
 
EctopicFetus said:
...If each person is happy in their situation be it, sdg, cmg employed good for you.

I think for some people it is better to not know how others are doing. there are EM docs making well north of 600/700k if you make 400k and are happy that might not be something you want to know.
Some folks will tell themselves those guys must be cheating, those guys must be overusing MLPs, those guys are committing fraud, those guys must be seeing 5 pph to earn that.. some are... many arent.
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I agree that it's best to find a situation in which you're happy and then stop worrying about what everyone else is doing. If you let every person who appears to have it better than you ruin what otherwise was making you happy, then you're setting yourself up for continued failure and disappointment. FOMO can destroy what is otherwise a very good life, if you let it.
 
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emergentmd said:
This is a life mentality and not just work. There are always easier ways to do anything. Just sit back, clear your mind, and think of solutions. Many tend to wallow in the situation rather than try to fix it. Sometimes situations just can't be fixed no matter what so the choice becomes either to accept/move on or wallow in "woes me".

Just some examples from work
1. We were a SDG who had the DOS based meditech EMR. This is by far the worse and its all typing. I can type super fast but found that my days were miserable acting like a secretary. So I created about 100 templates that covered 99.9% of charts. I was going to type it anyhow, so I just typed it into an online storaged, copied and pasted after changing a few details. I averaged a completed chart in 2 minutes while other docs took about 7 minutes. 5x20ppd = 100 minutes. That is 100 minutes for me to make money, go drink coffee, leave the ER, surf the internet, etc. No one ever complained b/c I was a top 2 RVU producer and went home right on the dot 90% of the time. The other guy who was a top RVU producer stayed 1-3 hrs ever shift. In the long run, this messes with your mind and one reason why I never got burned out even after 15 yrs. Simple fix, and some docs copied me after I explained to them what to do. Others kept being a secretary. I almost never had a down chart either b/c my charts read like a novel.

2. Our specialist/hospitalists became super busy and the slow ones sometimes would take 1-2 hrs to call back. Docs would page, wait after their shift ended to leave bc they rightfully so didn't want to pass this on to the next doc. After a few times of this, I left my cell with the clerk/txt the hospitalists to call me b/c I am going home. No one ever complained and I saved myself countless days of staying back. An 8 hr shift vs a 10 hrs shift is a huge deal.

I can go on and on but I learned to "game" the system and was by far the most efficient doc in our group. When I started to do locums, I again became the most efficient doc regardless of EMR/environment. Nurses loved when I worked b/c I got people out which allows me great latitude to take a bunch of breaks, stop seeing pts 2 hrs before my shift ended, surf the internet. When you are the fastest/most efficient doc, no one cares what you do or leave the ER. Be the slowest doc and they will give you the evil eye if you leave the department.

I can go on and on but I see this in life all the time. The amount of time people take to do simple tasks astounds me. I go in and out, and ever extra minute I save is a minute I can go take a nap or be with my family. Learn this early and work/life frustrations will almost disappear.
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This is what I do. See 2, get coffee, see 2, get coffee.
 
Siggy said:
...except someone has to cover the slow shifts as well. How's your volume at 4AM? What incentive is there to take a slow antisocial shift?
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Everyone works a square schedule. You want someone to work nights figure out the RVUs/shift and figure out the delta there then throw something in for someone working nights. It’s how we do it.
 
FWIW, there are plenty of reasons not to go to 100% RVU. I love it. You know what this is how the payers pay us. They dont pay us on Press Ganey, or how many stupid ass modules we do. Thats all noise.

See the patient, drop the bill, collect the money. This is how it works on the side you dont see why would you not be paid on this.

Every system has its issues. Assuming you have volume the RVU model is the best in my opinion. I have worked in a pure hourly with bonuses based solely on hours worked(Tons of issues), a mix of both where it was 50/50 and my current gig of 100% RVU based.

Probably because I am efficient I like the RVU model. It is slow, I go home, it is busy i just step up my pace.
 
EctopicFetus said:
FWIW, there are plenty of reasons not to go to 100% RVU. I love it. You know what this is how the payers pay us. They dont pay us on Press Ganey, or how many stupid ass modules we do. Thats all noise.

See the patient, drop the bill, collect the money. This is how it works on the side you dont see why would you not be paid on this.

Every system has its issues. Assuming you have volume the RVU model is the best in my opinion. I have worked in a pure hourly with bonuses based solely on hours worked(Tons of issues), a mix of both where it was 50/50 and my current gig of 100% RVU based.

Probably because I am efficient I like the RVU model. It is slow, I go home, it is busy i just step up my pace.
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I imagine 100% RVU would solve a lot of issues regarding people sitting around and not seeing a new patient for hours, or spending 30 minutes on a non emergent rash, which is what happebs at my shop.
 
GonnaBeADoc2222 said:
I imagine 100% RVU would solve a lot of issues regarding people sitting around and not seeing a new patient for hours, or spending 30 minutes on a non emergent rash, which is what happebs at my shop.
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I second Ectopic's love of pure productivity based employment. When I first started working at my shop, there was a guy who was very close to retirement who would see 1 PPH. I was always thrilled when I saw that he was the guy working with me because I knew I'd be making absolutely bank that shift.

If you want to slow down (within reason), you can as your colleagues don't get pissed. They simply take the money that otherwise could have been yours had you decided not to take a break. If you want to hustle, you can make a lot of money.
 
EctopicFetus said:
FWIW, there are plenty of reasons not to go to 100% RVU. I love it. You know what this is how the payers pay us. They dont pay us on Press Ganey, or how many stupid ass modules we do. Thats all noise.

See the patient, drop the bill, collect the money. This is how it works on the side you dont see why would you not be paid on this.

Every system has its issues. Assuming you have volume the RVU model is the best in my opinion. I have worked in a pure hourly with bonuses based solely on hours worked(Tons of issues), a mix of both where it was 50/50 and my current gig of 100% RVU based.

Probably because I am efficient I like the RVU model. It is slow, I go home, it is busy i just step up my pace.
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How do you adjust for different payors? You may get anywhere from $0-$400 per visit based on the payor but you may not know that for months. I assume the group sets money aside for expenses or do you have to cover that yourself?
 
Siggy said:
…so… not 100% RVU if the slow antisocial shifts are getting subsidized.
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I mean, yes, that's technically correct but really just pedantry. We do the same thing as ectopic does in our shop. Every shift you keep what you kill minus a small "tax" for various things. If you work a proportionally correct number of night shifts, your night tax = 0. If you work a lot of nights, your tax is negative and if you work less than a fair share, your tax is positive. We've done the math so that anyone who works more nights (or is a nocturnist) is compensated for the average decrease in volume seen overnight, plus a little something to sweeten the pot for the inconvenience of working nights.
 
JacobMcCandles said:
How do you adjust for different payors? You may get anywhere from $0-$400 per visit based on the payor but you may not know that for months. I assume the group sets money aside for expenses or do you have to cover that yourself?
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I know this was directed at ectopic, but not sure what you mean. You don't adjust for different payors. You keep what you collect. It all averages out in the long run.

Not sure what you mean by setting money aside for expenses. Do you mean that when you see someone you don't get the money right away and thus how do you deal with that? In our case, you get paid when the money comes in, so there's usually a ~3 month lag between when you see someone and when you collect income from that visit. When someone first starts, we basically float them a salary that we know will be less than their collections and we use their excess collections - salary to pay it back over time. Once the amount we've floated = the excess they've collected, the excess then goes straight to the doc. The practice doesn't make any money off of new hires in this way, it's basically an interest free loan.
 
BoardingDoc said:
I don't know what Mount makes, but MGMA data for EM from 2021 showed:
Mean: 368074
Std dev: 98561
10th%: 267054
25th%: 316553
Median: 360771
75th%: 415034
90th%: 468342

I can't speak to the accuracy of these numbers, and it's worth noting that this is the survey for 2021. Data is coming from covid time with crap volume. 90th percentile for the only other MGMA sheet I have shows 90th percentile as being $504298. That's from 2019. (Mean was ~375k, median ~363k)

My gestalt is that the current data from 2023 (if anyone has it, I'd love to see it) would show numbers which are similar to, and possibly higher than 2019.
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Fascinating info, thanks for sharing.
 
I do RV you at my shop, but you should be paid at least a base flat hourly. Because you have to show up to the shift regardless, if any patients show up or not, which is your time. Yes you get billed on the patients however, the ER needs to be staffed by a physician or you can’t bill at all because you’re not a hospital.
 
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Siggy said:
…so… not 100% RVU if the slow antisocial shifts are getting subsidized.
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We handle those deals individually. I can pay you $500 to work my overnight and I get a non overnight in advance. But that’s fair. The only way true 100% no side deals works is if either the volumes are consistent or everyone works the same schedule.

For us everyone works the same schedule unless you work out a side deal.
 
EctopicFetus said:
We handle those deals individually. I can pay you $500 to work my overnight and I get a non overnight in advance. But that’s fair. The only way true 100% no side deals works is if either the volumes are consistent or everyone works the same schedule.

For us everyone works the same schedule unless you work out a side deal.
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...and that's kind of my point. Pure RVU, in my mind, doesn't work. Neither does pure straight pay. There needs to be a floor, but also benefit for working hard and scraping up RVUs. Otherwise someone gets screwed.
 
emergentmd said:
This is a life mentality and not just work. There are always easier ways to do anything. Just sit back, clear your mind, and think of solutions. Many tend to wallow in the situation rather than try to fix it. Sometimes situations just can't be fixed no matter what so the choice becomes either to accept/move on or wallow in "woes me".

Just some examples from work
1. We were a SDG who had the DOS based meditech EMR. This is by far the worse and its all typing. I can type super fast but found that my days were miserable acting like a secretary. So I created about 100 templates that covered 99.9% of charts. I was going to type it anyhow, so I just typed it into an online storaged, copied and pasted after changing a few details. I averaged a completed chart in 2 minutes while other docs took about 7 minutes. 5x20ppd = 100 minutes. That is 100 minutes for me to make money, go drink coffee, leave the ER, surf the internet, etc. No one ever complained b/c I was a top 2 RVU producer and went home right on the dot 90% of the time. The other guy who was a top RVU producer stayed 1-3 hrs ever shift. In the long run, this messes with your mind and one reason why I never got burned out even after 15 yrs. Simple fix, and some docs copied me after I explained to them what to do. Others kept being a secretary. I almost never had a down chart either b/c my charts read like a novel.

2. Our specialist/hospitalists became super busy and the slow ones sometimes would take 1-2 hrs to call back. Docs would page, wait after their shift ended to leave bc they rightfully so didn't want to pass this on to the next doc. After a few times of this, I left my cell with the clerk/txt the hospitalists to call me b/c I am going home. No one ever complained and I saved myself countless days of staying back. An 8 hr shift vs a 10 hrs shift is a huge deal.

I can go on and on but I learned to "game" the system and was by far the most efficient doc in our group. When I started to do locums, I again became the most efficient doc regardless of EMR/environment. Nurses loved when I worked b/c I got people out which allows me great latitude to take a bunch of breaks, stop seeing pts 2 hrs before my shift ended, surf the internet. When you are the fastest/most efficient doc, no one cares what you do or leave the ER. Be the slowest doc and they will give you the evil eye if you leave the department.

I can go on and on but I see this in life all the time. The amount of time people take to do simple tasks astounds me. I go in and out, and ever extra minute I save is a minute I can go take a nap or be with my family. Learn this early and work/life frustrations will almost disappear.
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I love these and wish you would go on and on - might be something I haven't thought of (or others) - I think this would be a very valuable contribution if you're willing to type it out (see what I did there 🙂)

Maybe a new thread...
 
JacobMcCandles said:
How do you adjust for different payors? You may get anywhere from $0-$400 per visit based on the payor but you may not know that for months. I assume the group sets money aside for expenses or do you have to cover that yourself?
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Expenses come off the top. It’s rvu based so payer doesn’t matter. It’s not a straight ffs model because of the issue you brought up. Would suck to code and do numerous procedured to ssve a life. Take 2 hours and get paid 0 while the other doc sees 10 week insured ankle sprains and makes 3k while u made 0. Also prevents cheating the game. When no one cares about payer mix that’s a win imo.
 
If volumes are too low this logic works. My Ed’s all see 100+ a day. So patients always show up. When they don’t you go home early. Win either way imo.
 
It works it’s just that you have to align what people want. Different people want different things. Early in my career I did all nights. More money. Now I work few nights. I need less money. Being totally restrictive about this hurts both parties. What people work out individually is up to them. We don’t police these deals. That being said 10% of the rvus get you 10% of payroll regardless of when you earn those rvus.

I’ll say 75% of our group don’t participate in the night deal (either side of it) and are true pure rvu.
 
emergentmd said:
This is a life mentality and not just work. …

I can go on and on but I see this in life all the time. The amount of time people take to do simple tasks astounds me.
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I’m always amazed how some people always find a better, more efficient way to navigate life, while others always seem to find a way to make even the simplest tasks, complicated, frustrating and full of self-erected roadblocks.
 
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