ENT jobs

[fongool]

Any of you practicing oto's have opinions on plusses/minuses of

-multi-specialty group practice
-single-specialty group 5 partners or less
-very large single-specialty groups (15-20 partners or more)


I know practices will vary greatly depending on location, but all things being equal is my question.

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[Dunce]

Would anyone care to also comment on the pros/cons of working in or having a financial stake in a surgery center

 

[aggernodi]

It all has to do with personality. Consider a group like a family with many siblings. The bigger the family, the greater the chances for bickering, loss of control, arguing over what YOU want over what another physician/specialty wants over a limited piece of the financial pie, etc.

However, the downside of a small group is that you all need to REALLY get along for work to be pleasant. In a 2 man group, you almost need to get along as well as, if not better than with your own spouse... indeed, you will spend just as much time with your office partner than your own spouse.

Also, the smaller the group, the "weaker" your voice. But, the "bigger" the group, the more "unwieldy" and "bureaucratic" it becomes.

In the end, when you make a decision with what group to join, the MOST important question is not so much the overall setup, but whether you think you will get along with them and whether you detect any sort of underlying pathology present in the varying personalities within the group. It only takes ONE bad apple to make work miserable.

Regarding surgery centers... I do think it's great to have the option to buy into it, but remember, they are not going to give it to you free. You also have to become partner as well before you buy into a surgery center, and that's not cheap either.

Use me for an example:

I belong to a small single-specialty group (2 attendings).
I was offered partnership with a buy-in dollar amount of $150,000 plus an additional $1000 per month for 36 months.

We don't have a stake in a surgery center, but you can bet your whole life that IF I wanted a stake, that dollar amount will probably be another boatload of money as surgery centers aren't cheap. You can buy a stake for $50,000 for 1/100,000,000,000 of the surgery center.... OR... pay $1,000,000 for a larger share. Also factor in the inflationary pressures as well as decreasing reimbursements for surgical procedures. It's just easier with less headaches to own shares of a publically traded corporation like GE or Microsoft.

If you already are in debt from school, this is money that's going to be hard to come by let alone buy-in for partnership.

I guess what I'm trying to get at is the OPTION to buy into a surgery center is a nice perk, but do not allow this option to have veto-like sway. If the group and location are great, don't sweat over the fact if they don't have a surgery center buy-in option.

Just something to think about.

 

[aggernodi]

One last comment...

I personally did not want to work with someone a whole lot older than I. I was tired of being the "junior" person and did want to be treated as an equal at some point.

If you join a group where there are much older senior physicians, keep in mind that though on paper you may be equal to them after partnership, you may still ALWAYS be treated as the junior guy.

That's no fun...

 

[Louisville04]

I belong to a small single-specialty group (2 attendings).
I was offered partnership with a buy-in dollar amount of $150,000 plus an additional $1000 per month for 36 months.

QUOTE]

What is so advangtageous about being a partner if there are no employee or associate physicians or a surgical center? You have a huge buy in cost, you "eat what you kill", and you could be liable for neglience of your partner.

 

[aggernodi]

I belong to a small single-specialty group (2 attendings).
I was offered partnership with a buy-in dollar amount of $150,000 plus an additional $1000 per month for 36 months.

QUOTE]

What is so advangtageous about being a partner if there are no employee or associate physicians or a surgical center? You have a huge buy in cost, you "eat what you kill", and you could be liable for neglience of your partner.

You are very correct... You forget the additional shared responsiblities of running a practice as well. Really, the only advantage is you make a lot more money and you have control (you are your own boss). For my partner at least, he required partnership after the first year for all the reasons mentioned. I didn't mind because after working for one year as an employee, I realized that he and the rest of the office staff are all very good, honest, trustworthy, and fun people. It's FUN to go to work! Also, it helps that he has never, ever been sued and every single person I've come across loves him to death.

Indeed, based on your arguments, one could argue the best way to go is as a physician employee of an HMO (like Kaiser) or academics. Indeed, quite a few physicians go that route. Downside is lack of control and you do make less money. Also, you could be fired just like any other employee.

Also, as an FYI, the buy-in cost for me was actually much lower than average. Bascially, the buy-in was ALL the equipment (50% depreciated book value) in the office. You are buying-in to become a part owner... just like buying a house. So, in that light, the buy-in cost is actually pretty darn good!

 

[fongool]

150,000 one year out is quite a chunk.

Do most buy-ins like that have a salary reduction formula to pay it or do most in your position take out a loan to cover it?

Do partnership contracts then typically spell out buy-out formulas for retirement of partners and what is typical for that?

 

[aggernodi]

150,000 one year out is quite a chunk.

Do most buy-ins like that have a salary reduction formula to pay it or do most in your position take out a loan to cover it?

Do partnership contracts then typically spell out buy-out formulas for retirement of partners and what is typical for that?

Buy-in can be structered any way that you and your partners agree on. Everything is negotiable... even the buy-in amount.

I have no idea what most people do. I negotiated with my partner what made most sense for both he and I from our particular unique financial situation.

 

[resxn]

I agree with aggernodi, especially most of the stuff in his first post.

I have this to say about the practice options.

I interviewed with a practice of 26 ENT's who basically "own" the metro where they practice. They were impressive and you had access to just about anything you wanted. Except freedom. Your voice was small.

I interviewed in a few small single-specialty practices and didn't go with them because of the high cost of buy-in.

I went with single specialty start-up. I received a guarantee and all overhead covered for 1 year. I'm supposed to take that over at the end of the year and assume all overhead myself. We'll see how that goes. This is probably the hardest route but has potentially the biggest reward. You have to be very smart as to the location of the practice, the practice environment, and the ability to expand. I chose a suburb of one of the largest cities in the US. It has 1 full-time ENT for a population of 124K. Our academy estimates the need of 1 ENT for every 35K so there is great room for that growth. Also, I'm in an extraordinarily well-to-do area so I have very little indigent care, relatively little medicare, and lots of opportunity for the simple cash-cows in plastics (laser skin, laser hair, botox, blephs, etc). I also am busy enough within just a few months that the hospital tells me they'd support my search for another ENT already. Seems scary, but I like the idea of growing my business.

The one thing I'd disagree with aggernodi on is the surgicenter. We have an ASC affiliated with our hospital. There is only a $2500/share buy-in. You can own as many or as few as you like up to no more than 25% of the total shares (the hospital always owns 52%). The hospital takes all the risk so that there is no cash-call on a slow month. The average return on a share has been 29%/yr for the last 4 years. So let's say you put in 50K (20 shares to start), that would be 14.5K each year returned on average. Find a return like that in the stock market!

Again, in every facet there is a risk-reward. You just need to find the place where that balances out the best for you.

Also, I found when I was looking for jobs that the best ones in terms of payment where offered through headhunters. I had more than a couple asking me to move somewhere for $425K+ in the middle of butt-freaking nowhere. . That's ridiculous. But the best jobs I found were those that were off the radar on the national recruiter scene, but that were spread by word of mouth. It was luck that I found my job when I did and it was one of those that was not advertised, but by word of mouth.

 

[fongool]

Resxn

I'll be done summer 2008 if you need some help that soon.

I think we may be in the same area.

 

[TheThroat]

I am in a small single specialty group and will be talking about partnership today. I am the only oto in a fast growing 50K suburb (Mansfield), but haven't yet gotten as busy as resxn, obviously. My partner is a very well-respected guy in a 350K city just north (Arlington). Very much like what I got into.

Won't go into everything that aggernodi explained very well, but will give a few summaries:
-If you like control and want to "own" something eventually, private practice is the thing to do. You can make a comfortable living in either academics or PP, but most PP guys make more than academicians.
-If you have an interest in academics (teaching, research), have a fierce aversion to making any business decisions (personel, contracting, overhead, marketing), or have a desire to go into a field that requires residents (H&N/pedi oto/neuro-oto), then academics is the way to go.
-Surgery centers can be lucrative and usually are a fairly safe investment.

 

[resxn]

Just to be fair, Throat and I are not too far from each other, geographically, being in different suburbs of the same metro area. I think the only reason I got busy so quick is that there was only 1 ENT full time serving the population of 124k--a place in need of at least 3 if not 4 ENT's. The reason there was one is because unfortunately, one ENT died at a fairly young age just as this particular community has experienced a 1048% growth in population since 1990. My situation was very unique and I just happened to walk in at a very needy time for the population. That's why the research into your potential practice location is so crucial.

One of my fellow residents started practice in Denver right after residency and really just got up to speed in her 22nd month. She was very frustrated, but that town is super-saturated with ENT's and it's a very competitive market. There is not a lot of support between practices there for a number of varied reasons. She's now doing well, but had a lot of stress covering overhead in her first year or so.

Point is, in ENT you can generally make work what you want to make work, but just be knowledgeable.

 

[aggernodi]

I was also in a very unique situation when I joined my current practice. I walked into a job (word-of-mouth) where my partner was the ONLY ENT over a 2 county region of Virginia. If you count all the ENT's in my area, there would be 3 including myself over a 5 county region.

Location location location... Just as important as the physician(s) you join.

 

[jooce]

Resxn....pls check your inbox, I just sent you a private message.

 

[mstudent12345]

when people say that you can make more, what do they mean? how much is the difference, I know that theoretically anything is possible as a partner but what is the reality of things?

Thanks

 

[aggernodi]

Back when I was interviewing for jobs (both private as well as academic), the starting guaranteed income difference between the two was about $40,000 (private paying more). This difference is when comparing similarly located geographic areas.

 

[resxn]

Back when I was interviewing for jobs (both private as well as academic), the starting guaranteed income difference between the two was about $40,000 (private paying more). This difference is when comparing similarly located geographic areas.

I'd agree totally with that. Just to be right out in the open. I was offered a position as a general ENT junior faculty member at 2 academic institutions. The first was in the midwest and was for $190,000 with $40k (that was untouchable) added into a retirement fund each year. The second was for an academic institution in the Rocky Mountains who offered $210,000 flat partly paid by the University ENT dept, partly funded by the VAMC.

I was offered $250k for a private practice in the same midwest town. However in the same Rocky Mountain location, the best offer I could find was $195,000 in private practice.

In one suburb on the Carolina borders I was offered $375,000. In one in TN I was offered $350,000. The highest I heard was in butt-nowhere Ohio for $425,000. The lowest was in a different Rocky Mountain city for $165,000.

Basically the prices were all over the map and really reflected the market and the desirability of the location. Most of the high salary places I considered are still advertising for positions over a year later if that gives you any clue.

I think overall the gap between academics and private practice general ENT is closing, but it is still a difference enough to cause one to pause.

 

[chirurgino]

A slightly different question -- I've heard of some ENTs who have created situations where they are able to maintain an academic appointment and teach about 50% of the time, while also seeing and operating on private patients about 50% of the time.

Any opinions about the feasibility of such a plan?

 

[5150]

Sorry to be loading you guys with questions, but do any of you have experience looking for positions out west, namely California? Since pay seems to be generally lower for more desirable locations, I was wondering how the offers from California would stack up against some of the other regions of the country.

 

[Dunce]

A slightly different question -- I've heard of some ENTs who have created situations where they are able to maintain an academic appointment and teach about 50% of the time, while also seeing and operating on private patients about 50% of the time.

Any opinions about the feasibility of such a plan?

I have always found this to be an interesting and somewhat desirable scenario.

My med school is somewhat of a "hybrid" between academics fully controlled by the university and the private-practice aspects of the community hospital in which we participate most.
I constantly see the 50% academic 50% private set-up that chirurgino mentioned. This seems to happen most with the specialties that have no residency or fellowship program here and, thus, no true full-time faculty.

For example, there is no official Otolaryngology department at my school. However, there is a well-established private group located on the hospital campus with very strong ties to the med school. One out of the 6 or so physicians is a true faculty member in every sense of the term with heavy teaching responsibility to medical students in all four years. Also, the ENT elective offered to 4th year students is done with this group.

So, yes there can surely be situations that offer the benefits of private practice with the ability to maintain some variable focus on teaching.
I would imagine that this type of situation is not altogether uncommon in other parts of the country.

 

[aggernodi]

Ditto prior post...

I know that Yale has a similar setup via St. Rapheal's Hospital though they do have a full-fledged university ENT department. Duke does not anything like this... Don't know about other programs...

 

[resxn]

UConn had a small ENT department when I was a med student there. The residents received about 30-40% of their training from private practices who had faculty appt's. I don't know if that situation is still the same--that was over 10 years ago.

I have held academic appointments at 2 universities and had residents rotate with me about 30% of the time. It was elective for them to do so in their R-3 year. I never had a resident who didn't come in the 3 years I was involved just because I really tried to just let them operate as much as possible and didn't give them much scut work. The University of Nebraska Med Center utilizes two private practices to help train residents. Most of their peds experience comes through this.

I think in the right setting, you can definitely do the private/academic stuff. In all of the situations of which I've mentioned, the private practice docs received a minimal (like $10k) compensation or none for their teaching. Most of it was voluntary and done for benefits such as a faculty appointment.


To answer a completely different question, I looked at several job offerings in CA. It was just a microcosm of the country. I saw great salaries and terrible salaries depending on the practice environment at the time. There are a few jobs that open here and there in the large towns for great money, but nearly universally these are filled by word of mouth and not open advertising. You have to be aggressive to get hired in a place like Palo Alto, Capistrano/Dana Point, La Jolla or other uber-nice area and contact practices yourself. But it's possible.