First Job, lost in all the options

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assistantregionalERdoc

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Hello all, first time poster. I'll be starting my last year of residency here soon, and with that comes starting the job search. I've been in touch with a few different groups, but it's difficult to weigh all the details that are thrown at me. Most of my residency faculty have worked in academics their whole career, and I've pretty much decided that it's not for me. So hoping to get some input from the community here. What are your general thoughts on these options:

Job 1 - CMG, independent contractor (though I will have benefits through my wife), 80 min commute 1 way, would block shifts, 280/hr + 50K sign on, 27K volume with single physician + 1-3 APP on at a time. 12x12 or 6x24.

Job 2 - hospital employee, close to home, high volume, lots of docs, no APPs, 15x9, 250/hr, low group turnover

Job 3 - hospital employee, close to home, super low volume (1.2 pph) single coverage at all times, 170/hr, 16x8, nice people, might worry about losing skills (or not developing as an attending)

Job 4 - CMG, independent contractor, 30 minute commute, 2-2.5 pph, physicians + APP, 260/hr + 50K sign on, 10x12.

Any good decisions or mistakes you all have made that I can learn from? Am I missing the mark of what really matters? Thanks!

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low group turnover

I think you have your answer. Generally, when there is low group turnover, its because its a good job. And if the workload there turns out to be too much, you have a good backup at Job 3, 170/hr is not a bad backup to work at a "super low volume" place, but I wouldn't start out there.
 
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Hello all, first time poster. I'll be starting my last year of residency here soon, and with that comes starting the job search. I've been in touch with a few different groups, but it's difficult to weigh all the details that are thrown at me. Most of my residency faculty have worked in academics their whole career, and I've pretty much decided that it's not for me. So hoping to get some input from the community here. What are your general thoughts on these options:

Job 1 - CMG, independent contractor (though I will have benefits through my wife), 80 min commute 1 way, would block shifts, 280/hr + 50K sign on, 27K volume with single physician + 1-3 APP on at a time. 12x12 or 6x24.

Job 2 - hospital employee, close to home, high volume, lots of docs, no APPs, 15x9, 250/hr, low group turnover

Job 3 - hospital employee, close to home, super low volume (1.2 pph) single coverage at all times, 170/hr, 16x8, nice people, might worry about losing skills (or not developing as an attending)

Job 4 - CMG, independent contractor, 30 minute commute, 2-2.5 pph, physicians + APP, 260/hr + 50K sign on, 10x12.

Any good decisions or mistakes you all have made that I can learn from? Am I missing the mark of what really matters? Thanks!

2, it's a no brainer. Lower liability with no APCs, good hourly, probably better benefits as a hospital employee, enough volume and acuity to harden your skillset, close to home.
 
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Yeah an extra $30/hr without benefits isn't worth an 80min commute.
 
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80 minute commute is atrocious.

Option 2 by a landslide.
 
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Not having to "supervise" midlevels is worth like $20/hr itself.
 
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Some cmgs have low group turnover but it’s falsely inflated number. They have a lot of locums and some long term full timers who can’t leave the area. You’ll have to work at some bad places eventually either because you need to be in a certain area or because the place just becomes more malignant with time.

The only guarantee in life is change. Try to find a good place but don’t beat yourself up if you inadvertently end up with a bad group.
 
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Which region is this, major city ?
if my calculations are correct thats like 400k+/year no matter which job you choose.... just wow... and here i thought new grads were bringing in 250k/yr.
 
Which region is this, major city ?
if my calculations are correct thats like 400k+/year no matter which job you choose.... just wow... and here i thought new grads were bringing in 250k/yr.

Ummm, no. You shouldn't be making under 300K as an ED physician. Will there be some areas that may pay lower, maybe. But almost every one of my graduates signs a contract in the 350 range at least, many for more. The market is pretty good right now for us. I think if you sign a contract that is full time for under 300k, unless its a sleepy job where you see 1.0/hr, you are being taken advantage of. Or you are in academics (though I personally still wouldn't sign for under 300k for an academic job either).

Even in places like NY, where salaries have been traditionally lower than the high salaries you see in the Southeast, there has been a recent uptick in salaries. ACEPs 2018-2019 compensation report showed a 25% increase in EM salaries in NY and similar increases out west.
 
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I really appreciate the all feedback. For what it's worth, I'm looking in the midwest at locations some people may consider "not very desirable". Sounds like most people feel option 2 makes the most sense, which is where I was leaning. It would be a bit difficult not chasing the highest paying (loans suck), but I also want to be happy.
 
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Job 2 for all the reasons listed above with the added bonus that you have no 12 hr shifts.
 
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Are you expected to sign the midlevel charts at job 1? If so, that rate is hysterically low.
 
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I really appreciate the all feedback. For what it's worth, I'm looking in the midwest at locations some people may consider "not very desirable". Sounds like most people feel option 2 makes the most sense, which is where I was leaning. It would be a bit difficult not chasing the highest paying (loans suck), but I also want to be happy.
Dude. Job 1 sucks.

Has you in a car for 32 hours a month.

Essentially the same amount of money per hour when you compare apples to apples (w2 vs 1099).

50k signing bonus isn't that much.

27k volume is nothing to scoff at for single physician coverage. You will have absolutely no say in the hiring/firing of the midlevels you are supervising. I'm sure you are going to have to sign all their crappy charts too.
 
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I really appreciate the all feedback. For what it's worth, I'm looking in the midwest at locations some people may consider "not very desirable". Sounds like most people feel option 2 makes the most sense, which is where I was leaning. It would be a bit difficult not chasing the highest paying (loans suck), but I also want to be happy.
So Job 2 if I'm doing the math right will gross you about 33k/month. Let's be very conservative say that between taxes, benefits, and retirement that gets cut down to 15.5k. That's take home per month. You could pay off a 400k loan in ~5 years just taking half of that 15k take home and putting it towards your loans (90k/year at that rate).
 
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Ummm, no. You shouldn't be making under 300K as an ED physician. Will there be some areas that may pay lower, maybe. But almost every one of my graduates signs a contract in the 350 range at least, many for more. The market is pretty good right now for us. I think if you sign a contract that is full time for under 300k, unless its a sleepy job where you see 1.0/hr, you are being taken advantage of. Or you are in academics (though I personally still wouldn't sign for under 300k for an academic job either).

What about a sweat equity partner track?
 
2, it’s a no brainer
I really appreciate the all feedback. For what it's worth, I'm looking in the midwest at locations some people may consider "not very desirable". Sounds like most people feel option 2 makes the most sense, which is where I was leaning. It would be a bit difficult not chasing the highest paying (loans suck), but I also want to be happy.

What you'll realize later on is that these "big" sign ons don't really help you that much in the grand scheme of things. For starters, you can't really get a good feel for a new gig until you've been there a few months. If it's malignant, hostile work environment, high liability, etc.. and you want to leave, too bad because you've already cashed that sign on and are locked in for 2-3 years. Let's also break down the 50K. Let's say you work 140 hours a month x 12 = 1680 x 2 years = 3360. 50K/3360= $14.8/hr increase in compensation. In the grand scheme of things, that's really not that much man. Plus, that's not even taking into account taxes which would only give you about ~32.5K of that 50 to begin with. I know it seems like a lot, but it's really not. Go with the better gig.
 
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Agree with everyone else--job 2 is the best option Job 1 sounds like a ****show type of place, if they're offering the chance to do 24s at that type of volume, they likely have either a major staffing crunch or don't know wtf they're doing.

However, 135 hrs a month contacted is a lot I would advise you to negotiate it down to 120 hrs/mo and then go prn at one of the other places for an extra 1-2 shifts a month if you need it.

Finally, lol at 'low turnover'
 
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What you'll realize later on is that these "big" sign ons don't really help you that much in the grand scheme of things. For starters, you can't really get a good feel for a new gig until you've been there a few months. If it's malignant, hostile work environment, high liability, etc.. and you want to leave, too bad because you've already cashed that sign on and are locked in for 2-3 years. Let's also break down the 50K. Let's say you work 140 hours a month x 12 = 1680 x 2 years = 3360. 50K/3360= $14.8/hr increase in compensation. In the grand scheme of things, that's really not that much man. Plus, that's not even taking into account taxes which would only give you about ~32.5K of that 50 to begin with. I know it seems like a lot, but it's really not. Go with the better gig.


I like the way you broke this down. It definitely sounds like a good deal up front and a way to get rid of a nice chunk of debt. But working in a better environment for 2 years would be worth well more than $14/hr (not to mention not having to do the commute).

Finally, lol at 'low turnover'

Why lol at low turnover?
 
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You do not want to do 24 hour shifts at a place with 27k volume. That is literally zero sleep guaranteed.
Not sure how you would block 6 24s either.
 
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I like the way you broke this down. It definitely sounds like a good deal up front and a way to get rid of a nice chunk of debt. But working in a better environment for 2 years would be worth well more than $14/hr (not to mention not having to do the commute).



Why lol at low turnover?
The problem is (and I hope other about to be graduates realize this too) is that job 1 sounds like an absolutely horrible deal up front.
 
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Hello all, first time poster. I'll be starting my last year of residency here soon, and with that comes starting the job search. I've been in touch with a few different groups, but it's difficult to weigh all the details that are thrown at me. Most of my residency faculty have worked in academics their whole career, and I've pretty much decided that it's not for me. So hoping to get some input from the community here. What are your general thoughts on these options:

Job 1 - CMG, independent contractor (though I will have benefits through my wife), 80 min commute 1 way, would block shifts, 280/hr + 50K sign on, 27K volume with single physician + 1-3 APP on at a time. 12x12 or 6x24.

Job 2 - hospital employee, close to home, high volume, lots of docs, no APPs, 15x9, 250/hr, low group turnover

Job 3 - hospital employee, close to home, super low volume (1.2 pph) single coverage at all times, 170/hr, 16x8, nice people, might worry about losing skills (or not developing as an attending)

Job 4 - CMG, independent contractor, 30 minute commute, 2-2.5 pph, physicians + APP, 260/hr + 50K sign on, 10x12.

Any good decisions or mistakes you all have made that I can learn from? Am I missing the mark of what really matters? Thanks!

Late to the party, but ROFL at job 1. 27k volume? So slightly >3pph averaged over the day? And they allow people to do 24s at that shop? Helllllllll no.

If you're working the 12s instead, you figure those 3pph aren't actually coming in at a steady pace, meaning during the daytime you're probably going to be seeing more like 4pph to make up for the hour or two where noone comes in overnight. IDGAF how many midlevels you have working for you, if you have more than one remotely complicated patient coming in at a time, guess what? You're the only actual doctor there and it's apparently all on you. So are all the atypical presentations that your NP said "they just have cellulitis" (Nope, it was SJS), "it's their typical migraine" (that strangely presented as a thunderclap HA this time), etc etc etc.

I could continue ranting for hours on this. Job 1 sounds like a hellhole of a job that will A: be miserable to work at and B: definitely get you sued sooner rather than later.

I agree with everyone else that Job 2 sounds like the best. Job 4 likely second best.
 
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Job 1 - CMG, independent contractor (though I will have benefits through my wife), 80 min commute 1 way, would block shifts, 280/hr + 50K sign on, 27K volume with single physician + 1-3 APP on at a time. 12x12 or 6x24.

Don't take this job. The fact that they are trying to cover 27,000 visits a year with single physician coverage and even mentioning 24 hour shifts as an option tells me that they aren't serious about running a quality - or even a safe - ED. You will hate the commute. Just walk away. I'd take this job - for a million dollars an hour. I'd work a shift, and then retire. The fact that something like this even exists should be an object lesson to graduating residents.

Job 2 - hospital employee, close to home, high volume, lots of docs, no APPs, 15x9, 250/hr, low group turnover

Sounds decent. Don't underestimate the importance of employee longevity as a testimony to the quality of a workplace. People voting with their feet frequently or the frequent and long term use of locums physicians is a red flag.

Job 3 - hospital employee, close to home, super low volume (1.2 pph) single coverage at all times, 170/hr, 16x8, nice people, might worry about losing skills (or not developing as an attending)

Also sounds decent, depending on shift length. There is absolutely a threshold above which 24 hour shifts will cause chronic sleep deprivation. That threshhold is probably lower than you think because as volume increases the chance of patients trickling in in the overnight hours also increases.

Perhaps you could do some sort of a mix where you do a 0.5 FTE at job 2 and 0.5 FTE at job 3. But if you're only going to take one of them, choose door #2.

Job 4 - CMG, independent contractor, 30 minute commute, 2-2.5 pph, physicians + APP, 260/hr + 50K sign on, 10x12.

High on the PPH number but better than job 1. Remember that family physicians who see two new patients in an hour are doing so at a 2 pph clip in a clinic with advanced warning for what is coming in when and with much lower potential acuity. 2.5 pph is a fake CMG/ACEP target. Look for 2 pph for hour or less if you want long term job satisfaction and workplace safety.

There are other things that come into play...how hard is it to transfer patients? Where do they go (unless your hospital is large enough to keep everything in house). How responsive are consultants? What out of department responsibilities do you have (are you going to have to go up to the ICU on demand at night and do procedures for inpatiets?)? How much harrassment are you going to get from mid level management to meet customer service metrics? What is the medicolegal risk in the states where each of these jobs are located? Is there a significant population of non-English speakers in the community for which you will have to use a language line frequently, killing your throughput and increasingly your liability? Are you a receiving facility for an IHS hospital or clinic?
 
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I've worked at a 15k volume place where some days you will get crushed and see 40 patients in a 12 hour shift. Single coverage for 27k volume? No thank you.

The full time gig I signed for is 20k (24 hrs doc coverage and 12 hrs MLP). Even that place has the ability to become terribly busy. 27k is probably 38-40 patients on average in a 12 hour shift. And that's average. Imagine a busy shift, maybe 50-55 in a shift? You will be responsible for all of them, regardless of whether that person was just seen by the MLP and you never saw that person. Job 1 is literally making you responsible for 35 percent more patients than what I'll be seeing at my gig, but it's paying you only 7 percent more than what I signed. Sounds terrible.
 
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Hello all, first time poster. I'll be starting my last year of residency here soon, and with that comes starting the job search. I've been in touch with a few different groups, but it's difficult to weigh all the details that are thrown at me. Most of my residency faculty have worked in academics their whole career, and I've pretty much decided that it's not for me. So hoping to get some input from the community here. What are your general thoughts on these options:

Job 1 - CMG, independent contractor (though I will have benefits through my wife), 80 min commute 1 way, would block shifts, 280/hr + 50K sign on, 27K volume with single physician + 1-3 APP on at a time. 12x12 or 6x24.

Job 2 - hospital employee, close to home, high volume, lots of docs, no APPs, 15x9, 250/hr, low group turnover

Job 3 - hospital employee, close to home, super low volume (1.2 pph) single coverage at all times, 170/hr, 16x8, nice people, might worry about losing skills (or not developing as an attending)

Job 4 - CMG, independent contractor, 30 minute commute, 2-2.5 pph, physicians + APP, 260/hr + 50K sign on, 10x12.

Any good decisions or mistakes you all have made that I can learn from? Am I missing the mark of what really matters? Thanks!

Mind sharing which region of the country this is? Curious about where to expect these types of offers
 
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Job 2. No APPS (woohoo!), low turnover, sounds like the hospital is invested in the docs. Salary is good. High volume and lots of docs is good this soon out of residency. Sounds like a nice place to grow. You are more protected as an employee, too.

Job 1 sounds like hell, and I should point out that if you are an IC they cannot legally determine how many shifts you work. Commute is time wasted, stress, cancels out the extra dinero. They fact that they would consider 24 hour shifts at such a shop is insane and indicative of poor management. 27k volume is also insane for single coverage. Avoid at all costs.

Job 4 doesn't seem to have much to offer beyond a sign-on bonus, and those are overrated. 2.5 pts per hour is doable; do you have to see APP pts on top of that? Once again, if you are a contractor, they can't demand a minimum number of shifts.

Job 3 sounds fine, but it pays significantly less. It doesn't sound bad, but you might deskill a bit this early in your career. Mainly, I don't see any advantage to this job.
 
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The advantage of no mid-levels cannot be overstated.
 
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Would go #2 if definitely planning on staying in the area long term. What is the initial pay at job #2? Is job #2 W2 or 1099? - do they offer health insurance? The drive is certainly long.

Aside from the distance and initial higher pay, Job #1 sounds awful. 2.5 pph without scribes?! - that's insane.

There's a reason bad places have high turnover and good places don't.

Unless you are planning on leaving after 1-3 yrs, I would almost certainly take job #2.

You should buy a house closer to there or (better decision) rent until you know you are staying for the long haul. Why did you buy a house in residency?
 
Would go #2 if definitely planning on staying in the area long term. What is the initial pay at job #2? Is job #2 W2 or 1099? - do they offer health insurance? The drive is certainly long.

Aside from the distance and initial higher pay, Job #1 sounds awful. 2.5 pph without scribes?! - that's insane.

There's a reason bad places have high turnover and good places don't.

Unless you are planning on leaving after 1-3 yrs, I would almost certainly take job #2.

You should buy a house closer to there or (better decision) rent until you know you are staying for the long haul. Why did you buy a house in residency?
 
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Initial pay at job #2 is lower (being your buy in) at $150/hour W2 for scheduled shifts. Open shifts for pickup above obligated shifts are 225/ hr. Obviously base hourly pay will go up as you make full partner starting earlier on.

And my house is a smaller townhouse. Bought for $180k and equivalent units are now selling for $210k+. I’m not obligated to stay there but will try while laying down loans initially.

My only hold up is the commute which would probably be ~60 minutes each way. Ideally I would try to mitigate the stress with a Tesla / Cadillac super cruise / autopilot. But obviously being far away, you are screwed if any severe weather or accidents come along.
Mistake #1 as a new attending: buying a fancy new car you can't afford.
 
My only hold up is the commute which would probably be ~60 minutes each way. Ideally I would try to mitigate the stress with a Tesla / Cadillac super cruise / autopilot. But obviously being far away, you are screwed if any severe weather or accidents come along.

I will have a 1 hour commute to my new job. The difference is that my job is 1099. So I plan on hiring someone for roughly 90-100 a day for driving me to work and then driving me back home after my shift. I'll deduct that expense as a business expense. Accounting for taxes, the true cost for having someone drive me will be around 50 bucks. But.... If i also deducted Mileage, that's almost free
 
I will have a 1 hour commute to my new job. The difference is that my job is 1099. So I plan on hiring someone for roughly 90-100 a day for driving me to work and then driving me back home after my shift. I'll deduct that expense as a business expense. Accounting for taxes, the true cost for having someone drive me will be around 50 bucks. But.... If i also deducted Mileage, that's almost free

I'm a fan of hiring somebody to drive a long commute for you in order to take a better job if the calculus works out...but consider running these deductions you wish to take by your accountant.
 
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I'm a fan of hiring somebody to drive a long commute for you in order to take a better job if the calculus works out...but consider running these deductions you wish to take by your accountant.

Yeah. For starters, it's my understanding you can't deduct mileage if you're just going from home to work and back.
 
This is correct unless you can justify traveling to multiple sites. Can’t usually be done just for one site.
 
Home office to ED counts
 
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Yeah. For starters, it's my understanding you can't deduct mileage if you're just going from home to work and back.

So even if my LLC is contracted to work at 2-3 different ERs? Primary site I'll do 11 shifts a month, and maybe 1-2 shifts at other places. What's the point of 1099 if I can't deduct expenses
 
Make sure you have an accountant who will back you on that. I’m pretty aggressive and that’s one that I don’t take.

So let me get this right. Do you claim W2 or 1099? Because if 1099, you are self employed 1099 and not claiming to have an office? Where do you work? Is your office your hospital ED? If so, you are not a 1099. You must be a W2 claiming to be a 1099. If so, you are breaking the law and you aren’t getting benefits from your employer.
 
So even if my LLC is contracted to work at 2-3 different ERs? Primary site I'll do 11 shifts a month, and maybe 1-2 shifts at other places. What's the point of 1099 if I can't deduct expenses

I believe you could deduct if you worked a shift and went immediately to another ED to work a second shift, but traveling from home to work isn't deductible. I do wonder if you could do a telemedicine consult from your home office before every shift, thereby traveling from one work site to another, and maybe even deduct a work 6,000 lb gross weight vehicle, but that seems dicey.

You can still deduct licensing fees, conferences in vacation locales, large retirement contributions.
 
I believe you could deduct if you worked a shift and went immediately to another ED to work a second shift, but traveling from home to work isn't deductible. I do wonder if you could do a telemedicine consult from your home office before every shift, thereby traveling from one work site to another, and maybe even deduct a work 6,000 lb gross weight vehicle, but that seems dicey.

You can still deduct licensing fees, conferences in vacation locales, large retirement contributions.

I'll ask my accountant. Last year, my accountant was okay with deducting mileage for my traveling to work for my 1099 gigs. She Co signed my tax returns. She asked me a few questions about how the scheduling worked, and was okay with it. But my primary job then was still w2 income. Either way, even if I can't get mileage, I could probably do gas, car insurance, car payments at least I would think. I will literally change the ownership of my car to my LLC if I have to :p

Really... If I have 400k of business income, if I even deduct 30k as a business expense, that's not even 10% in business expenses, that should be considered one lean and well run business by the government.
 
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