Fantastic Job Offers and I Don't Know Which to Pick. Help!

[AD04]

Before I start, I want to say thank you to the forum contributors -- especially to the more experienced people who take time to share their wisdom. (You know who you are.)

I followed the advice from the forum and have been inundated with more offers than I could entertain. (I now understand what a hot girl experiences.) But now I have a dilemma. I have been blessed with two amazing offers and don't know which one to pick.

Here are the offers:

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Offer #1 -

location: rural (beautiful place, I don't mind location)

patient: sub-acute, mood disorders (with some addiction), well-to-do (select insurance and cash accepted)

offer: almost $400k / yr (1099) for 15 pts / day (M - F), will pay more if I work Saturdays (optional), malpractice covered

bonus offer:
- all my living expense (housing, transportation, food, entertainment) will be taken off
- it will be high-class living (with housekeeper, living next to lake, world-class food, and upper-class activities such as horse-back riding, boating, big game hunting)
- basic amenities included (gym, pool, spa, etc.)
- I could probably save 90%+ of my after-tax income while living very well

background information: CEO is a seasoned charismatic businessman, started and maintained successful businesses in various fields and various countries, well-connected with powerful / rich organizations, it is a very special place with the resources and connections to expand worldwide

personal thoughts:
- increased income will come from taking on more responsibilities (he values competence and hard-work)
- I will be the youngest among the decision-makers (potential to advance as people retire / cut-back on work)
- no ownership structure
- I will be a linchpin but I will not replace CEO in the near future (as he is harder to replace than I am)
- he can mentor me on business aspect once he trusts me (we didn't talk about this, but I have no doubt he will like my work and take me under his wing)
- risk: lack of control -- must keep CEO happy (I am merely a nobleman / courtier, while he is king)
- CEO and I have similar beliefs which facilitates a good working relationship

worst case (unlikely scenario): if things don't work out, I'll have a hefty financial cushion; FU money achieved after 8 - 10 years (assuming no growth in income from year 1)

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Offer #2 -

location: one of the richest places in the US

patient: mostly stable, few addiction, well-to-do (select insurance and cash accepted)

offer:
- production-based (very good split) -- w2 and pass-through distribution
- first year estimate range from lower-to-mid $300k / yr for 40 hours a week or less (based on practice's numbers and historical data)
- after 5 years or less, income will be over $400k / yr (for same hours)

bonus offer: after each year, will get % ownership of practice until cap is hit (will be minor partner, source of passive income)

background information: owner is also a physician with history of success, relatively young, ambitious, trustworthy and open (showed me the books)

personal thoughts:
- increased income will come from growing the practice and possibly expanding to other locations
- owner-physician will teach business aspect
- I expect I will function as true partner (as capable as owner) in 5 yrs or less
- optional: additional source of passive income through real estate investing (which will also be taught)
- owner and I have similar thoughts and I think we will work well together for a very long time

worst case (unlikely scenario): if things don't work out, I will have knowledge how to start and operate a very successful practice (and can work anywhere by creating my own work)

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Both places are really motivated and gave me offers during the on-site visit.

Both places offer potential for high-income. There are more patients than they can help. Decision makers are entrepreneurial. I estimate I can reach high six-figures. Maybe even more. I can't say which offer is best from long-term point of view.

Based on my on-site interview, I trust the owner-physician more than the CEO (gut feeling). Maybe my trust stems from having more control with the offer from owner-physician than from the CEO. Both have incentives to keep me happy. Both don't micro-manage. Both are easily accessible and willing to entertain my suggestions.

Both offer little risk: No non-compete clause. No restriction to outside work. No out of pocket expenses. Lots of flexibility and freedom.

Both are mutually-exclusive. I cannot do both. Whichever I pick, I will dedicate my efforts and grow the organization and build my reputation in the area.

Please advise me on which you would pick and why?

Thanks!

(BTW I am absolutely convinced psychiatry is the new dermatology.)

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[legendkiller]

The first one seems better in my opinion

 

[TexasPhysician]

It’s hard to say if those numbers are good or bad without more details. What is call, how much time for evals/follow-ups, hours, support staff, admin time, emr/paper, supervision requirements, ancillary income streams possible, etc, etc.

I’ve seen a few entrepreneurs talk a good game, but then the job ends up being pure trash. I’m not saying these aren’t good offers, but I can’t come close to agreeing based on limited info

 

[Stagg737]

Without more information it sounds like there's two major differences between the two options.

Job 1 provides a very luxurious lifestyle with the ability to save/invest a huge portion of your income. You could essentially work there for 10-12 years and then work 2 days a week the rest of your life and do just fine. If you value lifestyle + financial security and don't need $300k/yr to live off of, this sounds like a dream come true.

Job 2 sounds like it will have higher COL, but also sounds like you'll get more exposure for gaining business acumen and developing your career. So if you're really looking to build a business yourself (whether it's that business or your own some day), this sounds like the better option.

I could be totally wrong, but that's how I'd look at it based on what you've written above.

 

[AD04]

It’s hard to say if those numbers are good or bad without more details. What is call, how much time for evals/follow-ups, hours, support staff, admin time, emr/paper, supervision requirements, ancillary income streams possible, etc, etc.

I’ve seen a few entrepreneurs talk a good game, but then the job ends up being pure trash. I’m not saying these aren’t good offers, but I can’t come close to agreeing based on limited info

Excellent concerns. These are what I know:

---

Offer #1 -

call: available by phone for my patients (few calls during nights and easy to manage -- i.e. trazodone for sleep), optional to work Saturday for additional pay

time for evaluations / follow-ups: up to me but here is what I expect
- new: 45 minutes - 1 hour (ancillary staff will have gathered a lot of the data before I see patient)
- follow-ups: 30 minutes (time with patients encouraged, therapy encouraged)

hours: 7:30 AM - 4:30 PM (not including being available by phone)

support staff: lots (billing, therapist, people to speak with family, etc.)

admin time: 2x / week of treatment meetings

EMR / paper: EMR

supervision requirements: none (I made sure of this)

ancillary income: none (no ownership structure)

---

Offer #2 -

call: available by phone for my patients (whatever is normal for private practice), no weekend call

time for evaluations / follow-ups: up to me but here is what I expect
- new: 45 minutes - 1 hour
- follow-ups: 20 - 30 minutes (therapy up to me)

hours: 8:00 AM - 5:00 PM

support staff: yes (billing, therapist, etc.) -- i.e. prior authorization will be handled by ancillary staff

admin time: whatever is normal for private practice

EMR / paper: paper for now (with plans to transition to EMR)

supervision requirements: none (no mid-level providers in practice)

ancillary income: yes (portion of profits depending on ownership percentage)

Without more information it sounds like there's two major differences between the two options.

Job 1 provides a very luxurious lifestyle with the ability to save/invest a huge portion of your income. You could essentially work there for 10-12 years and then work 2 days a week the rest of your life and do just fine. If you value lifestyle + financial security and don't need $300k/yr to live off of, this sounds like a dream come true.

Job 2 sounds like it will have higher COL, but also sounds like you'll get more exposure for gaining business acumen and developing your career. So if you're really looking to build a business yourself (whether it's that business or your own some day), this sounds like the better option.

I could be totally wrong, but that's how I'd look at it based on what you've written above.

Pretty good summary.

 

[FlowRate]

Sounds like the locations are very different, as well. Unless job #2 is in CT, in which case I guess they may be more similar than like urban CA and somewhere rural.

 

[TexasPhysician]

The time allotments of the appointments in private jobs should be specified in the contract without a range unless it is production based. If production based, it should state that you have control over appt times. Ranges worry me. How many new eval slots are dedicated per day? You are on nightly call for these? Who determines whether you are paged for little things or not? Admin time if given should be tightly specified to handle refills, calls, etc.

I’m not trying to hassle you with these questions, so I apologize if it comes off as such. I’ve seen friends be told glamorous things by business people, and the results have generally been quite bad.

 

[dl2dp2]

offer: almost $400k / yr (1099) for 15 pts / day (M - F), will pay more if I work Saturdays (optional), malpractice covered

bonus offer:
- all my living expense (housing, transportation, food, entertainment) will be taken off
- it will be high-class living (with housekeeper, living next to lake, world-class food, and upper-class activities such as horse-back riding, boating, big game hunting)
- basic amenities included (gym, pool, spa, etc.)
- I could probably save 90%+ of my after-tax income while living very well

I'm assuming this is an insurance driven-facility based job. 15 pts of 99213/90833 is roughly $150-$200 per visit, depending where you are at Medicare rates. The total revenue is between 500k and 700k, which shave off 30% overhead gives you 400k. This number makes sense. Assuming you are full from day 1. This is a heavy case load compared to an average psychiatrist. I would hope that you have good ancillary services (i.e. secretary, therapist, etc). At any one time, this census (assuming only med mgmt appts, since I don't see how you can fill your spots with therapy patients) ~ 500 people would include fairly sick people who would demand a lot of off hour work.

It's doable. It's tough (I would say the total work hour would be around 60 hours a week) and you should be psychologically prepared, but it's doable.

Offer #2 -
- production-based (very good split) -- w2 and pass-through distribution
- first year estimate range from lower-to-mid $300k / yr for 40 hours a week or less (based on practice's numbers and historical data)
- after 5 years or less, income will be over $400k / yr (for same hours)

The numbers seem fairly realistic to me as well, but would depend a lot on exactly how distributions are calculated. In fact, this is somewhat on the low end. A typical practice of this type usually you work LESS than 40 hours a week for a similar total comp.


The flavors of the two jobs are quite different. I personally would pick the second since it allows more flexibility and having lived in a smallish town I would not do it again -- location matters a lot to me. I think money itself is not a very important concern. The more important concerns are: 1) I'm assuming you are a single male: are you looking to meet someone in the near future? If so, I think the first job may not be a great choice. OTOH if you are already married with teenage children and have a stay at home childcare and love spending time outdoors on weekends, situation changes. A lot rad onc jobs have this location restriction issue--this is a MAJOR issue. One of the things you might want to ask for #1 is whether they'd allow telecommuting...which would expand your options a lot.. 2) Are you looking for a high ceiling or a high floor? The second job has a high ceiling. 3) Do you care about living in a rural community... are you an immigrant? Do you know what it's like? Spa treatment really doesn't get far if that's the only game in town.

 

[AD04]

I'm assuming this is an insurance driven-facility based job. 15 pts of 99213/90833 is roughly $150-$200 per visit, depending where you are at Medicare rates. The total revenue is between 500k and 700k, which shave off 30% overhead gives you 400k. This number makes sense. Assuming you are full from day 1. This is a heavy case load compared to an average psychiatrist. I would hope that you have good ancillary services (i.e. secretary, therapist, etc). At any one time, this census (assuming only med mgmt appts, since I don't see how you can fill your spots with therapy patients) ~ 500 people would include fairly sick people who would demand a lot of off hour work.

It's doable. It's tough (I would say the total work hour would be around 60 hours a week) and you should be psychologically prepared, but it's doable.

The ancillary service is good. My role will be mostly medication management as therapy will be provided by the therapists. However, ample time is provided to listen, to build rapport, and to give brief therapy as needed.

The numbers seem fairly realistic to me as well, but would depend a lot on exactly how distributions are calculated. In fact, this is somewhat on the low end. A typical practice of this type usually you work LESS than 40 hours a week for a similar total comp.

The flavors of the two jobs are quite different. I personally would pick the second since it allows more flexibility and having lived in a smallish town I would not do it again -- location matters a lot to me. I think money itself is not a very important concern. The more important concerns are: 1) I'm assuming you are a single male: are you looking to meet someone in the near future? If so, I think the first job may not be a great choice. OTOH if you are already married with teenage children and have a stay at home childcare and love spending time outdoors on weekends, situation changes. A lot rad onc jobs have this location restriction issue--this is a MAJOR issue. One of the things you might want to ask for #1 is whether they'd allow telecommuting...which would expand your options a lot.. 2) Are you looking for a high ceiling or a high floor? The second job has a high ceiling. 3) Do you care about living in a rural community... are you an immigrant? Do you know what it's like? Spa treatment really doesn't get far if that's the only game in town.

You have pretty good crystal-ball skills. I respect that.

1. Regarding the location, I really don't mind. I can live anywhere and among anyone. I can live lavishly or simply. My main peeve is wasting time commuting and both places don't waste my time.

2. I prefer high ceiling. Can you tell me what the second job will look like (layout of the business) once I reach the high ceiling? My time is limited and most likely won't come from seeing more patients. Where will the additional income come from? What would a high ceiling income be?

 

[rich10900]

I would base your decision from that gut instinct of yours you reference in the original post with the owner/physician (option #2). Gut instincts in our field lead us to good decisions in many ways. Sounds like you will work alongside a doctor that has proven this over the past eight years with an amazing track record, high income and wonderful staff/patients. He even showed you 2015, 2016, and 2017 personal and corporate returns all while practicing in one of the most beautiful parts of the country (It was proven to you despite others on this very forum as non believers). You will own a percentage of the practice and make plenty more than 400K, easy, on a 4 1/2 day work week, all while on a w-2 with matching retirement etc. The owner/physician probably shot the numbers low so when you make more you are happy, its better business etiquette than to throw around high numbers and disappoint. Call, there is none. Weekends...spent on a boat snorkeling, fishing or down at the Keys. Upwards of a million dollars is being spent on a new office that is one of the prettiest in the county and owned by the practice at a hospital, unheard of. You even get to pick out your room, but all have amazing window views with a lake, palm trees and the hospital in the background. I don't know, I might be impartial.....as I am option #2.

 

[Stagg737]

2. I prefer high ceiling. Can you tell me what the second job will look like (layout of the business) once I reach the high ceiling? My time is limited and most likely won't come from seeing more patients. Where will the additional income come from? What would a high ceiling income be?

In regards to the bolded you seem to have answered yourself already:

bonus offer: after each year, will get % ownership of practice until cap is hit (will be minor partner, source of passive income)

- increased income will come from growing the practice and possibly expanding to other locations
- I expect I will function as true partner (as capable as owner) in 5 yrs or less
- optional: additional source of passive income through real estate investing (which will also be taught)

Being partner will help, especially if the practice grows significantly. Real Estate can also be a great side hustle if you're looking for passive income. Real estate can be dangerous if you don't know what you're doing though. Idk what the ceiling would be in your specific case, but I've worked with psychiatrists who've earned high six figures and one who earned 7 figures due to a unique business model and the types of jobs he took. So a high ceiling can be very high, but it's also a very unique situation. The second job sounds like it would have the higher long-term ceiling, but you'd have to work more to get there. If you love what you're doing though, I think the reward would be worth the wait.

 

[calvnandhobbs68]

I would base your decision from that gut instinct of yours you reference in the original post with the owner/physician (option #2). Gut instincts in our field lead us to good decisions in many ways. Sounds like you will work alongside a doctor that has proven this over the past eight years with an amazing track record, high income and wonderful staff/patients. He even showed you 2015, 2016, and 2017 personal and corporate returns all while practicing in one of the most beautiful parts of the country (It was proven to you despite others on this very forum as non believers). You will own a percentage of the practice and make plenty more than 400K, easy, on a 4 1/2 day work week, all while on a w-2 with matching retirement etc. The owner/physician probably shot the numbers low so when you make more you are happy, its better business etiquette than to throw around high numbers and disappoint. Call, there is none. Weekends...spent on a boat snorkeling, fishing or down at the Keys. Upwards of a million dollars is being spent on a new office that is one of the prettiest in the county and owned by the practice at a hospital, unheard of. You even get to pick out your room, but all have amazing window views with a lake, palm trees and the hospital in the background. I don't know, I might be impartial.....as I am option #2.

lol as in you are the owner of option 2 OP is referencing?

Smooth move OP.

Was just down in Florida and thinking theres probably two big medical markets down there right now....derm/plastics and psych.

 

[Merely]

Wait what just happened in this thread...? Did the owner of option 2 just post here??

 

[zolof]

Wait what just happened in this thread...? Did the owner of option 2 just post here??

I am trying to figure out what is going on too.

 

[Shufflin]

Wait what just happened in this thread...? Did the owner of option 2 just post here??

Gripping! Hold on to your seats...

If true, then option 2 just got a lot more interesting because now people will private message rich10900 which will give him even more candidates to chose from, and possibly knock out the OP. Unlikely, but how ironic would that be.

 

[AD04]

Gripping! Hold on to your seats...

If true, then option 2 just got a lot more interesting because now people will private message rich10900 which will give him even more candidates to chose from, and possibly knock out the OP. Unlikely, but how ironic would that be.

Lol. This turned dramatic fast.

The flip-slide is maybe someone will PM me and try to recruit me which will give me even more options. After all, there may be a reason I'm getting these types of offers.

 

[dl2dp2]

Interesting. Florida is a great state for private psychiatry. I'm sure your practice will do well, and I think more people should consider moving down. Most of the sunbelt states and Texas are definitely a growth area for private psychiatry since the upper income population is definitely growing, and there's a paucity of qualified mental health professionals.

Florida is also where it's highly possible to have a high end therapy practice, since psychotherapy has a stronger tradition in South America.

 

[FlowRate]

Lol. This turned dramatic fast.

The flip-slide is maybe someone will PM me and try to recruit me which will give me even more options. After all, there may be a reason I'm getting these types of offers.

Well, here I am hoping you'd discuss which advice you followed and referenced in your OP for the benefit of those of us who will be doing this next year...

 

[zolof]

Could be good. I have worked locums all over south Florida. However private practice in florida is a little different than other places. In winter population swells in Florida with the snowbirds but Summer and Fall tends to die down even for the locals that own homes and condos. Just something to think about, I don't know how much it would impact private practice but definitely restaurants and other businesses take a hit.

 

[Sushirolls]

Option 2 overall seems better. My experiences have reflected that hospital CEOs are hard to trust, and only consider 'providers' to be nothing more than widgets to do their bidding. Another doc at least has understanding of the nuances of the job, and should you ever need to confront on quality of care issues, they will know what you are talking about and not down play them. You will learn more with option 2 and even if the jobs isn't what you hoped it would be (most likely the case) in a few months / years, you will have acquired a greater skill set of billing / CPT code / office staff / etc that will be portable to your next chapter of life.

 

[AD04]

Well, here I am hoping you'd discuss which advice you followed and referenced in your OP for the benefit of those of us who will be doing this next year...

I would love to give back to the community. I'll write up a job search guide around April 2019. If I don't get to it by then, feel free to remind me.

The guide will cover how to look for a good job. However, that is just one part of the equation. What you are offering (i.e. who you are) is just as important and will determine if you seal the deal or not.