ENT after residency

Discussion in 'Otolaryngology' started by resident108, 05.12.14.

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  1. resident108

    resident108

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    I'm a PGY3 ENT resident thinking about general community practice. Any foreseeable disadvantages to not doing a fellowship? Any way to enter academics later in my career as a general ENT?
    What are typical hours and call requirements in your (or known to you) group community practice?

    I'm in a busy academic program and residency is a great learning environment. I enjoy what I do, but it is clear to me that family, friends, and hobbies are extremely important and I'd like a fulfilling career that does not involve several nights and weekends working. I am content not doing complex cases. Is this even possible? My program attendings work hard - 7-6 for the most part, surgical days can go to 8, call about 1 in 6 weeks which is busy call, research on the side, handful of presentations to prepare for annually, administrative meetings, attending conferences, etc. For the most part, after a weekend off doing other things, I don't miss the above academic activities. Either this means I am burnt out or I'm actually not too interested in academic endeavors.

    Would appreciate any thoughts related to this.
     
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  3. DrBodacious

    DrBodacious H-D Sportster 883C 10+ Year Member

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    In "general community practice," there is a very wide range of possibilities with regards to employment.

    A big decision point is self-employed vs practice-employed vs hospital-employed. I think any of these models has a potential to have either a very busy lifestyle or a less busy lifestyle.

    Self-employed means either solo practice or being a partner in a group. Usually, in solo practice, you are going to work full time due to quick drop offs in efficiency and overhead, but it is certainly possible to work part time. You could either waste overhead by not utilizing your office, or you could share office space with another ENT or a non-ENT and run your business independently. After all, most offices are closed on the weekends, so therefore most offices are really running at 5/7 capacity as "full time," so you could just make that 3/7, instead.

    Being a partner makes it easier to cut back on office hours without driving up your overhead percentage. Really, you could work any number of days that you want. You would need to have a relationship that contributes in a fair way to the practice, or the other partner(s) would kick you out. If you work less, you should probably expect to pay a higher percentage of the revenue you generate as overhead (IMO).

    Practice-employed and hospital-employed positions are pretty variable, also. I know people who have part hospital-employed contract with a reasonable salary to match. When it gets down to it, the hospital is going to have the same efficiency issues as you would managing yourself in private practice, so a lot of positions will push you to be as productive as possible. I depends on how desperate the hospital is to have you on staff, how tight their budget is, and how "loose" the administrators and hospital system is with their pocket books. The hospitals have a little more leeway, because they cash in on the facility fees from your surgeries (which is big $$$) in addition to your office revenue. But in general, you do not profit as much for any given encounter, compared to being self-employed. So, if you think about the amount of patient care related work it takes you to make a given salary, employed positions are going to require more patient care related work compared to being self-employed.

    Being hospital employed, there are a lot of things you do not have to worry about with regards to practice management, but you will still have to meet with administrators and office managers. You still can have issues with scheduling, issues with the competency of the office staff, and it may actually take longer to document complaints and make changes as opposed to just doing what you want. I hired a practice manager that does a great job, and does it the way I want it done. Overseeing billing is maybe the biggest headache in self-employment, but you are going to be responsible for coding and documentation in pretty much any job.

    Call requirements are going to be dictated by the hospital by-laws and how many people are available to take call. Again, it depends on if they want or need you. If you are the only ENT in town, they may let you have privledges to operate while taking call q 2 or q 3. If there are more than 2 of you in town, then you will probably have to take call at that freqeuncy. In the city I did residency, you got out of the call pool at age 55. In my current city - you take call until retirement. Some communities have separate facial trauma call schedules.

    Disadvantage to not doing a fellowship - More so in a highly saturated area (esp major city - San Fran, Chicago, NYC etc.) In a smaller city I do not think it matters much. If you really want to do general, I would think you would loose a lot of the other skills doing only the fellowship-related scope of practice for an entire year or two. I do chronic ears, sinus, thyroids and parotids and if I took a year off of doing any one of those, I would probably feel much less comfortable with them. In a big city, there are probably more detailed referral patterns to sub-specialists that you are less likely to see as much of that stuff without a fellowship. It is probably nice when you have a group practice that one person does peds, one does sinus, one does otology, etc, but that is hard to come by, I think.

    Way to enter academics later in career - I can't give specifics. You can always do anything you put your mind to. It will probably cost you a lot of time and money to make that type of career change, but if that ends up being your passion, I would say you can always do it.

    Hours - Just think about a clinic day. You could start at 7:00am or 10:00 am. You could take a 2 hour lunch or no lunch at all. You could see 12 patients a day or 70 patients a day. When I was interviewing at a hospital based practices, they seemed fixated on how many patients a day I saw in residency. I would guess I am at least in the top 25% with regards to speed and efficiency in both clinic and surgery, but I don't think I realized what they were getting at and didn't really want to sell myself that way. You are going to be more valuable to a practice or hospital if you are faster, and really, that is one of the reasons that when you finish residency, congratulations, you are back to the bottom rung of the ladder once again - you have to prove your financial viability. Academics lets you escape from that to a large degree by excelling with academic duties.

    Some other general advice: Contact as many practices and hospitals as you can to feel out different opportunities. You will probably see advertisements and get head-hunters calling you for high need jobs, but there are a lot of other jobs out there if you just cold call. If you already know the area you want to practice in, I would contact every possible practice position to see what they have to offer. If a doctor is so busy he desperately needs a partner, he may be too busy to actively seek candidates. And also consider starting a solo practice. If you know you only want to work 4 days a week, then you can set that as a goal.
     
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  4. resident108

    resident108

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    Thank you so much for the reply - that's very helpful. I'm looking to stay in the suburbs of highly saturated cities so complex cases will definitely be referred to those academic centers. Looking around, most of the practices I see here are practice employed or hospital employed.

    As a generalist, what is your schedule like? Do you ever miss academic environment or see the need to do a fellowship? I really do like the variety and if I did a rhinology or laryngology fellowship, I'm not quite sure what I would gain since I'm not particularly interested in the very complex anterior skull base resections or laryngeal reconstruction and I don't want a dedicated practice of just sinus disease - I like having some FESS, laryngeal injection medialization, etc.
     
  5. OtoHNS

    OtoHNS ENT Attending 5+ Year Member

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    From what you've said, I don't see a reason for you to do a fellowship. I didn't and I'm in a similar situation to what you want (private practice in outlying suburbs of a saturated metro area). I do the cases I want to/feel comfortable doing and I refer out the stuff I don't want to do/don't feel comfortable doing.

    The one way you could do a fellowship and focus on one area of ENT would be to join a large ENT practice (at least 8-10 other docs) and be their subspecialist in the practice who the other docs will refer their challenging cases to. This would be more likely to work for laryngology or otology, less likely for rhinology (because most ENTs like doing sinus and it pays really well, especially for in-office balloons).
     
  6. DrBodacious

    DrBodacious H-D Sportster 883C 10+ Year Member

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    I am in my first year out in solo practice, FWIW.

    I have full clinic days Monday, Tuesday and Thursday. 8 - 5 with a one hour lunch break. I see between 30 and 45 patients (this includes a few allergy shots a day usually). Finishing up my charts and correspondence and reviewing some business things usually takes me until 6:30 - 7:30 pm. If I put my mind to it, I can do this stuff more quickly, but after a busy clinic day I tend to take my time

    I do surgery at the hospital for bigger cases every Wednesday, usually a full day. OR starts at 7:30 - I have gone as late as 8:00 pm with 5 or 6 bigger cases and maybe an add on trauma case, but usually done around 3:00 pm. I have a slow day here and there (half day today). I do small cases at the surgery center every Friday morning. Friday afternoon I leave open for clinic procedures, and catch up on paperwork. I have a PA who does clinic with me on clinic days, and sees medicaid patients and does ENG, VLS and allergy procedures while I am in surgery. He at least pays for himself, and handles 95% of the medication refills, medication prior authorizations, helps arrange referrals and tests. So, the PA is a big help. I am on call every 4th night on average and cover 2 hospitals that are in close proximity.

    I have been getting a lot of non-surgical referrals lately (tinnitus, hearing loss, vertigo, LPR, allergy, etc) and my surgery schedule isn't as busy, while my new patients are getting booked 3 weeks out. So, next week I am adding on another half day of clinic in place of surgery time. That is one nice thing about solo practice, is to have that type of flexibility.
     
  7. resident108

    resident108

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    Thank you DrBodacious - thats a very busy day of clinic. I can easily see documentation taking 1-2 hours daily. You seem to be quite busy working 60 hour weeks. Do your calls require for you to come in at night?

    Any other private practice schedules greatly appreciated.
     
  8. resident108

    resident108

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    bump - any other community practice schedules , reasons for not doing a fellowship, reasons for? At what point in residency to start approaching groups for jobs? Thanks - much appreciated.
     
  9. resxn

    resxn 7+ Year Member

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    My schedule is a lot different than many of my colleagues on here whom I respect. For perspective, I finished residency in 2004. I am the managing partner of my 7 person practice and also am the Chief of Surgery and Vice Chief of Staff of a decent size hospital in my area, though, so I do have to cut back my time in clinic to handle administrative duties to some degree.

    I generally operate on my bigger cases (thyroids, parotids, etc) on Tues AM. Tue afternoons are admin until 1500 when I take off to pick up my daughter from school and be home with family earlier than my typical day. Thu is my outpt surgery day. I sometimes have clinic in the afternoon, sometimes not depending on the ebb and flow of the demands. Mon, Wed, Fri are generally clinic although sometimes when things get busy like Nov and Dec Wed AM's are more OR. I will not see more than 14 people in a 1/2 clinic day which runs from 0800-1130 or 1330-1630. So most patients I see will be 28 in a day. I find that if I spend less time with patients than that, I can't keep them happy enough that they stay with me. I practice in an affluent suburb that is highly competitive with a few other ENT's and do not have the luxury of a 5 min clinic visit.

    I've negotiated with the 2 main hospitals where I operate that I will not be on official call, but will be available at any time to take calls from the ER or Floor and if I have the time to see them I will. If I don't, they get transferred. They won't pay me for call at these facilities so I will not be on a formal call schedule and, thus, avoid all the legal EMTALA pitfalls. However, most ENT's where I'm at will not take call at all at these hospitals, so it works well for me and my group. If they decide to pay me for call, I'll accept a formal call schedule. It's my way to force their hand. I will go in if it's life and death and I can handle it, but I'm simply not coming in to see a non-threatening PTA, for example. I usually see most floor consults because it keeps me in good standing with the hospitalists and other specialists who chat with the PCP's regularly.

    I am not counting allergy patients in my clinic schedule (at least those coming in for their shot or SLIT pickup) because the nurse takes care of them and I just bill. Typically, that's about 10 more for me. It also doesn't count the number of times I run our CT scanner on a pt for our clinic because the billing goes to the doc who ordered it (generally 2-3 per 1/2 day). I am in the office with the CT scanner and it's the only one for our 4 offices so it's pretty busy.

    I usually use a scribe to do my notes. Best thing I ever did. I hate charting. I'd shoot myself if I ever did any more months where I had 2 hours of charting at night at home.
     
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  10. resident108

    resident108

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    Fantastic - thanks for the reply. That sounds like a great practice - general ENT with some big cases (parotids and thyroids), minimal call duties requiring overnight issues, and some early evenings to spend time with family. I think I've ruled out a fellowship after reading these forums and talking to numerous people. General seems to offer the most flexibility.
     
  11. DrBodacious

    DrBodacious H-D Sportster 883C 10+ Year Member

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    Just to point out that resxn's job is not something you walk in to out of residency. Competing and succeeding in an affluent area with a good payor mix is not a given, just with regards to building/maintaining a good reputation with patients and referring colleagues. Managing partner and steak in multiple in-office ancillary services and standalone ventures take a lot of skill and effort to acquire. These opportunities may not be available if someone else is there first, so planning the location for your practice can make a big difference. Of course, "there is always room for the best on top," but you have to know what you are cut out for.

    On a separate note, now that the thread was bumped, I have gotten a lot better with my EHR, and I now can see the same volume and get home by 5:30-6:30. I am also merging with another ENT and working on expanding the hearing aid business in my practice.
     
  12. resxn

    resxn 7+ Year Member

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    Good points, Dr.B. FWIW, I really wasn't trying to say I was any more or less successful than the other guys on the forum. Rather, I was trying to point out I'm not as busy as other guys and cannot afford to see as many patients because of the competitiveness of my area and the volume of other garbage I have to handle. That directly translates into fewer dollars from what I do in clinic. However, hopefully, I have been able to make that up plus some due to the other work. I do agree with you completely on the amount of work it takes to become successful, though, and the importance of selecting your location. I will be the first to admit that I'm not the smartest ENT around, but I will not be out-worked by anyone. Period. I have slowly learned to work smarter which has absolutely improved my QOL.
     
  13. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor 10+ Year Member

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    I'll weigh in as well for what it's worth.
    I've been in practice for a little over two years. I work in a pretty rural area in Appalachia but not far from some bigger places. The patient base is generally poor and not well educated, but very trusting.
    I am in the office M,Tu, Friday. I see pts from 8-5 and average ~ 30 people.
    I work at the surgery center every Th. I average 8-10 cases. Can range from just tonsils and ear tubes to septums, FESS, skin cancer excisions with flap, open neck biopsy, laryngoscopy/biopsy, sistrunk, tympanoplasty, etc. Most of the time it's just tonsils, tubes, septum, fess. One Monday a month I am at the main OR. This tends to be medically fragile pts, younger children for T&A that need admission/observation, and thyroids/parotids. I probably do 3-4 parotids a year and 8-10 thyroids a year. I am off every Wednesday.
    My practice is a pretty general ENT practice with a heavy emphasis on allergy. We have a robust allergy clinic that helps support our schedule and allow us to work 4 days a week. Based on the reported numbers I've seen, I make more than the "average" ENT does, especially considering my favorable work schedule. This is almost entirely due to our allergy clinic and our location as my patient volume and OR volume would probably put me in the middle of the road for pay otherwise.

    Hope this information is helpful. There are a lot of practice styles. I don't do big cases much anymore and prefer to ship those out. One of the nearby practices here still does the big stuff and rounds on them etc. I'm not really interested in doing that. I like the work I do and am well compensated. But I don't live in the most interesting place and working with poorly educated patients that all smoke has its challenges.
     
    Last edited: 02.18.15
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  14. Daodejing

    Daodejing What goes up, must come down 2+ Year Member

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    This has been really great information. Thanks for all of the contributions.
     
  15. resident108

    resident108

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    what is a decent, reliable place to get numbers on starting salary and average salary 5 years down the line? I'm getting to the point of seeing some contracts but really have no clue as to what is appropriate and what is not. I'm in a suburb of NY outside of NYC (within 30 miles). What are most ENTs making and how are most people addressing student debt - paying them off as quickly as possible or doing a 25-year IBR plan hoping that the remainder gets excused. Appreciate the advice, thank you!
     
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