Hiring a Nurse Practitioner

[Adam Smasher]

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Many of us here have asserted half-jokingly that anyone can do podiatry. In fact, my single biggest complaint about the podiatry career path continues to be that we pay too much to be too overtrained to handle 90% of the patient complaints that present to us in an outpatient setting, whether it's private practice or a hospital clinic. Hence my overused lobster jokes that we bottom-feed off the leftover work that no one else in the medical world is willing to do, and we're too saturated to turn that work away. But money talks and BS walks and I put up my own money to actually hire a NP to provide podiatry services in my office.

I know I'm not the first podiatrist to hire a NP, but I am the first in my area to do it, and of all the PP podiatry groups I've scouted over the years, I know of maybe 2 with a NP in the group. We hired someone mid-November. For now, the ROI question on this hire remains to be seen, and I'll report back every quarter or so. However, at least in terms of the impact on our office culture and how patients received her, this is shaping up to be one of the best business decisions I'll ever make.

Why not hire another DPM instead?
This is along the lines of the "appropriate level of care" determinations that health admins make. We don't keep patients hospitalized who can go to rehab, and we don't keep patients in rehab who can go to their home with VNA/home PT services. Likewise, the only thing dumber than undertaking 7 years of training and 4 years of student loans in order to render palliative foot care is hiring someone with 7 years of training and 4 years of student loans to do it. Frankly, I can't afford to hire an ACFAS Fellow at $460k or whatever the survey was claiming they earn when I won't make adequate use of this person's talents. I share everyone's contempt for the lowball associate offers that exist out there, and I don't want to contribute to that problem, but even so, it's not a viable business strategy to hire someone who is likely to work with me 2 years max if I can't give them a reason to stay.

The NP workflow
Instead of bringing another DPM into our mix to do the same thing my partner and I are doing, our NP will handle patient overflow. In theory, routine care patients would get moved onto her schedule, while the DPMs have schedule space for new pts. If routine follow up pts have a question she can't answer, they are reappointed to one of the DPMs or maybe we poke our heads in the door if it's really a crisis. Those of you who have mid-levels working with you in your hospital gigs understand this already, but it bears stating explicitly: the NP doesn't necessarily generate income but instead frees up time for the DPM to be more productive, and that's how profits increase. At least that's how I hope it works, I'm building this plane mid-flight.

Why not make your MAs do RFC? Why not have a RN do it?
I'm almost certain in my state MAs aren't supposed to do it. I understand a certified foot care nurse can bill medicare for trimming toenails but it's technically not in their scope to diagnose conditions like diabetic neuropathy and PVD, so I'm not sure how that business works. This means this pt is still on the doctor's schedule. What I'm aiming to do is move them off my schedule completely apart from maybe an annual foot screening or whatever nonsense the ADA wants me to do.

The NP job market
While the BLS reports some really astronomical projected job growth for NPs, they are being cranked out assembly line style by their colleges. Commenters here have remarked that NPs are earning $200k+ and probably that's true. But I was able to post a salary range that was well below the typical Upperline DPM associate package and still attract a goodly number of candidates.

NPs are very often employed by health systems and corporate entities who will take their pound of flesh out of them in return. NPs get used and abused. In the course of interviewing candidates, I heard about crazy urgent care schedules with 10-12 hour shifts seeing 60 pts. NPs get shifted around their employers commuting between sites that could be 45 min apart. Every person I interviewed didn't care how grimy podiatry is, all they cared about was having normal hours and a lighter workload.

And this was my biggest selling point: I could offer flexibility, a work environment they could control, and some professional respect. Our NP and I are on a first-name basis, I don't make her call me Dr Smasher. Because the DPMs are still going to take on new pts, that leaves the bulk of the charting off the NP's plate, just copy-paste notes. The NP we hired wanted a 4 day work week so I let her have it. We still have a benefits package including medical, dental, and a 401k match. Plus I'm paying for her malpractice insurance--it was only $3k!!!

The biggest adjustment for applicants I think was many kept asking "how many hours are my shift?" and I had to keep telling them, this isn't shift work, this is a salaried position. We have operating hours, and the amount of hours you have to work before/after hours depends on how effective you are with your time. Some candidates wanted to know if they could work 3 12-hour shifts and I had to explain my office isn't staffed for 12 hour shifts, that's the difference between a health system and a small business.

Our Newest Team Member
I really hit the jackpot. She is diligent and kind. She has a warm personality that my patients love. She is more motivated to learn about podiatry than many of my own classmates were while we were on rotations. It so happens she already has a bit of experience in a wound clinic. As noted above, I need to see if she pulls her weight financially, credentialing has been slow, but I'm confident this is going to pay off.

To Our Dear Leaders
I know our podiatry alphabet soup (CPME/APMA/etc) overlords are lurking in these forums. So this should interest them. If I can teach someone to do podiatry in a month, why does it take you so many years to do it?

 

[Retrograde_Nail]

I have an NP in my hospital based practice.

She sees all my post ops and does all the diabetic foot care. She even does ingrown toenails. She rounds for me in the hospital for any surgical patients that gets admitted. She also rounds for me for all my patients on the inpatient list when I am on call. Even weekends when I am on call.

She also does some wound care and is able to suture. She closes skin for me so I can bounce to another room to start another case. She can do splints and casting as well.

She is worth her weight in gold.

I get to focus on high level visits and surgery. I've become incredibly efficient. I have less total patient visits but doing the same amount or even more RVUs per month as before but with a lot less stress.

There is really no need for the hospital to just hire another podiatrist to split the work. It accomplishes nothing other than make your current on staff physician angrier. Just ask any of your ortho colleagues when the hospital hire their 4th-5th hand surgeon or 4th-5th adult reconstruction/joint doc.
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What is even crazier about having an NP is that their scope of practice is already more extensive than a DPM (by law). This NP you hired could be someone who does your medical clearances for your surgery patients. She could do full body wound care in your office. It would all be perfectly legal. Podiatry has zero flexibility like this.

 

[DYK343]

I have an NP in my hospital based practice.

She sees all my post ops and does all the diabetic foot care. She even does ingrown toenails. She rounds for me in the hospital for any surgical patients that gets admitted. She also rounds for me for all my patients on the inpatient list when I am on call. Even weekends when I am on call.

She also does some wound care and is able to suture. She closes skin for me so I can bounce to another room to start another case. She can do splints and casting as well.

She is worth her weight in gold.

I get to focus on high level visits and surgery. I've become incredibly efficient. I have less total patient visits but doing the same amount or even more RVUs per month as before but with a lot less stress.

There is really no need for the hospital to just hire another podiatrist to split the work. It accomplishes nothing other than make your current on staff physician angrier. Just ask any of your ortho colleagues when the hospital hire their 4th-5th hand surgeon or 4th-5th adult reconstruction/joint doc.
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What is even crazier about having an NP is that their scope of practice is already more extensive than a DPM (by law). This NP you hired could be someone who does your medical clearances for your surgery patients. She could do full body wound care in your office. It would all be perfectly legal. Podiatry has zero flexibility like this.

Other than seeing 99024s and freeing up time to move onto the next case is there any other financial benefit to a NP?

I am going to assume you do not get billing credit for the patients as a NP is independent?

 

[Retrograde_Nail]

Other than seeing 99024s and freeing up time to move onto the next case is there any other financial benefit to a NP?

I am going to assume you do not get billing credit for the patients as a NP is independent?

I can bill assistant fee for when she scrubs into cases. Not sure how much more RVU credit I get or if it just helps the hospital collect more money for the surgery. Not sure.

But whatever she does in clinic or for inpatient consults I can not claim credit for. So prob not a lot of DIRECT financial credit.

But INDIRECTLY I can do 7-10 cases in a day and be done by 5-6pm instead of 8-9pm or later. And I am doing a lot less notes. That's less work for the same amount of productivity. The amount of time I've been able to have with my family has sky rocketed since she has come on. I am also exercising more than I have in 8 years of practice. Health is wealth. The healthier I am the harder I can work and the more I can utilize her. So INDIRECTLY extremely profitable for me so far.

 

[Adam Smasher]

From an owner/ administration perspective, it's about ensuring physicians are doing high-complexity high-RVU work most of the time.

Look at the ED. We want the docs covering strokes and chest pain because high acuity stuff reimburses better than a lacerated finger or STI exposure. That's why there's a mid-level in the fast track section. If the emergency doc is often times treating low level stuff, there's an opportunity cost there because they could have been doing high complexity work for the facility instead.

It's lovely that retro has more family time and is living healthier, but I'll leave it to everyone to guess how much admin really cares about that.

Same logic for me in my office. If it takes weeks for a higher reimbursing pt encounter to be seen, that's delayed productivity for me and lesser cashflows. I'm optimistic that I can transfer most of my followup nail care pts to her schedule, freeing me up to see higher reimbursing encounters sooner and more per day. Which brings me to something I left off in the OP:

Why not just tell your low reimbursing RFC patients to F off?
Because then it creates a market for another DPM to open up across the street from me. By retaining the pts within my practice, I can consolidate market share within my community. Like a lobster protecting its territory.

 

[Retrograde_Nail]

It's lovely that retro has more family time and is living healthier, but I'll leave it to everyone to guess how much admin really cares about that.

They don't even though they say they do. If they really cared they would have hired one from the start but that has NEVER happened to any hospital employed podiatrist in the history of the profession. I would be amazed if there is someone out there who got hired by a hospital and they hired them an NP for the first day of work. Hospitals just don't care about podiatry.

It took 2.5 years of generating generating 90-95 percentile production and a nasty e-mail for them to even consider it. I rolled the dice and won.

 

[Stormblest]

At what point of workload would you think about asking for an NP? I’m thinking about asking for a second MA to help in clinic but wondering if I should just ask for an NP. They have brought up bringing on an NP to help me because I have gotten pretty busy in clinic at least. Surgery I only have 2-3 a week on average right now.

 

[Retrograde_Nail]

At what point of workload would you think about asking for an NP? I’m thinking about asking for a second MA to help in clinic but wondering if I should just ask for an NP. They have brought up bringing on an NP to help me because I have gotten pretty busy in clinic at least. Surgery I only have 2-3 a week on average right now.

Trajectory for me was:

Year one - 8000 RVUS - Only one RN to help with clinic
Year two - 10000 RVUS - Got two RNs to help with clinic
Year three - 13000 RVUs - during the middle of that year (based on my pace) I asked for an NP. But I had to ask for it.

If they are already offering now I would take them up on that before they forget or change their mind.

 

[Hybrocure]

But do they know fracture classifications

 

[Stormblest]

But do they know fracture classifications

First day you must teach them STJ axis in order for them to treat patients.

 

[heybrother]

 

[Feli]

I will say what probably half the ppl reading this are thinking: how will you get NP to stay when they have job options of toenails/wounds or peds or ortho or derm or family practice or ER or etc etc clinics for jobs? They are not only doing podiatry, they're assigned to doing the lower end pathology within podiatry. It seems like a tough sell beyond maybe the honeymoon period?

Another DPM (associate) knows they'll be doing that RFC, consults, wound stuff. They are locked into it, and they face the barren podiatrist job market. So, with the benefits NP can get at many other jobs and the likely $$$ premium over their FP, UCare, etc job options that it'd probably take to retain them doing podiatry awhile, I don't see the savings. Jmo.

Midlevels make 100% sense for busy productive MDs (esp procedures based). The midlevels cost a third or less of hiring a doc for MD/DO... but its much closer in podiatry. In addition to pay, most podiatrists don't have this backlog of surgeries piling up if they could turf RFC to midlevel ( @Retrograde_Nail does, but he's 1 in 500).

(and fwiw, I probably have no say in the topic as I decided against hiring associate DPM. I see it as a risk in terms of staff/space/supplies... and in most areas without non-compete, you are just bringing in competition. No reason for that if one has already won the game.)

....Interesting topic for sure... if an already saturated specialty adopts midlevels to any significant extent (in pod supergroups, VAs, etc), it'll be all kinds of messy. Food for thought and evolving topic, absolutely. 👍

 

[dtrack22]

I will say what probably half the ppl reading this are thinking: how will you get NP to stay when they have job options of toenails/wounds or peds or ortho or derm or family practice or ER or etc etc clinics for jobs? They are not only doing podiatry, they're assigned to doing the lower end pathology within podiatry. It seems like a tough sell beyond maybe the honeymoon period?

Another DPM (associate) knows they'll be doing that RFC, consults, wound stuff. They are locked into it, and they face iur barren podiatrist job market. So, with the benefits NP can get at many other jobs and the likely $$$ premium over their FP, UCare, etc job options that it'd probably take to retain them doing podiatry awhile, I don't see the savings. Jmo.

Midlevels make 100% sense for busy productive MDs (esp procedures based). The midlevels cost a third or less of hiring a doc for MD/DO... but its much closer in podiatry. In addition to pay, most podiatrists don't have this backlog of surgeries piling up if they could turf RFC to midlevel ( @Retrograde_Nail does, but he's 1 in 500).

(and fwiw, I probably have no say in the topic as I decided against hiring associate DPM. I see it as a risk in terms of staff/space/supplies... and in most areas without non-compete, you are just bringing in competition. No reason for that if one has already won the game.)

....Interesting topic for sure... if an already saturated specialty adopts midlevels to any significant extent (in pod supergroups, VAs, etc), it'll be all kinds of messy. Food for thought and evolving topic, absolutely. 👍

You forget that NPs were all RNs. Cutting people’s toenails is nothing to them (in terms of monotony or level of “gross”). I think if they get paid well based on the local market for their services, and you give them autonomy to treat the patients/pathology you’ve deemed NP-worthy, a podiatry group wouldn’t have any more or less difficulty keeping an NP than any other clinic.

 

[Sendin_Toes_2market]

Hospital based surgical pod here. I want a PA/NP. I built the surgical program, I’m not sharing my wRVUs with someone who’s going to leave in 2-3 years. I may just be greedy.

As state above. Probably not until I have 2 surgery days a week. Currently only 1. Then it makes sense.

 

[Adam Smasher]

I will say what probably half the ppl reading this are thinking: how will you get NP to stay when they have job options of toenails/wounds or peds or ortho or derm or family practice or ER or etc etc clinics for jobs?

According to indeed, there's a larger primary care group in my area offering $110k+benefits to hire a NP for their circus of a clinic, so that's where the bar is for me...

Apart from that, everyone I interviewed was someone mid-career looking to scale down. As noted above, they've been through the ringer already of corporate healthcare bs and don't want to go back. They want an easier life and to be treated respectfully. They don't care if it's toenails or a-holes. As long as I keep mine happy, she'll stay. Hopefully.

I guess it's the biggest professional gamble of my career. If it works out, this could reshape podiatry. There's nothing stopping an enterprising NP from starting a foot focused practice on their own ("Foot Care Nurses, LLC") and boxing podiatrists out of their own specialty. And if it doesn't work out, well, at least I'll always have toenails.

 

[heybrother]

Internet suggests that Medicare pays 85% for services rendered by a NP. What are you experiencing in regards to Medicare/commercial insurance?

 

[Boba Foot]

They want an easier life and to be treated respectfully.

Nothing says professional respect like a non-qualifying old boomer coming in and saying, "I'm just here for my pedie cure" and addressing you by your first name.

 

[Retrograde_Nail]

Nothing says professional respect like a non-qualifying old boomer coming in and saying, "I'm just here for my pedie cure" and addressing you by your first name.

I hate when patients call me by my first name

I also hate when they joke, when I'm running late, that I was too busy golfing

Or when my doofus long term chronic wound care patients say they are paying for my future boat

 

[Adam Smasher]

Internet suggests that Medicare pays 85% for services rendered by a NP. What are you experiencing in regards to Medicare/commercial insurance?

I'll get back to you after more claims turn around. I never conceived anyone would be reimbursed less than we are.

 

[Sole Badguy]

If it works, it works. I'd say go for it if it means more money/benefits in your pocket. Get your bag

I will say - I've noticed the occasional hospital job post for a non-surgical (possibly minimal surgery) pod with expectations specified as such in the job description. I'm assuming this is a way to solve the same issues being brought up here i.e. RFC glut, being on call, and potentially serve as a flex option for wound/post-op care and simple procedures when needed but still allowing for the majority of cases to go to the more surgical pods on staff. No reason why this option couldn't be on the table for the hospital-employed pods here. I imagine that the money being saved by hiring a PA/NP over another pod won't go to a hospital pod the same way that it would to a PP pod owner. This is all speculation, of course - if having an NP/PA works better with your workflow, I'm not here to break your stride. It's just that the job market could always use some more formal podiatry job openings, and having on a non-surgical pod feels like a very 1:1 fix.

 

[Retrograde_Nail]

If it works, it works. I'd say go for it if it means more money/benefits in your pocket. Get your bag

I will say - I've noticed the occasional hospital job post for a non-surgical (possibly minimal surgery) pod with expectations specified as such in the job description. I'm assuming this is a way to solve the same issues being brought up here i.e. RFC glut, being on call, and potentially serve as a flex option for wound/post-op care and simple procedures when needed but still allowing for the majority of cases to go to the more surgical pods on staff. No reason why this option couldn't be on the table for the hospital-employed pods here. I imagine that the money being saved by hiring a PA/NP over another pod won't go to a hospital pod the same way that it would to a PP pod owner. This is all speculation, of course - if having an NP/PA works better with your workflow, I'm not here to break your stride. It's just that the job market could always use some more formal podiatry job openings, and having on a non-surgical pod feels like a very 1:1 fix.

We have a non surgical pod on staff with us who stays in their lane and only does routine foot care but this DPM does do some minor wound care and also sees random MSK visits which fall through the cracks. This DPM also does a lot of outreach which can be tiresome. Candidates for these types of non surgical DPM jobs are becoming less and less because the profession keeps graduating "surgeons". Nobody wants to accept these non surgical DPM positions. If they do accept these non surgical jobs then they will be the first people to go to admin saying they are really a surgeon and deserve to do surgical cases. Then you have opened a can of worms.

I still think hiring an NP/PA is a way better option than a non surgical DPM. I also think we, as a profession, should STOP pushing these non surgical podiatry jobs as it continues to add to the confusion of what podiatry is.

 

[Sole Badguy]

We have a non surgical pod on staff with us who stays in their lane and only does routine foot care but this DPM does do some minor wound care and also sees random MSK visits which fall through the cracks. This DPM also does a lot of outreach which can be tiresome.

Understandable - but wow, still very busy even with that kind of set-up, that's wild

Podiatry: "sometimes we do surgery like F&A ortho, sometimes we don't"
I guess the "good" thing about everybody having adequate formal surgeon training is that, if you are trained as such and can get a surgery-focused job, then that's great and the system works as expected - but if you can't (more likely than you'd think) or you find that you're not about that life, then you can dial it back and pursue the non- or minimal-surgical positions. Same like any other MD/DO surgical specialty. I'd still give a non-surgical podiatrist request a consideration - but I sympathize and say that they really shouldn't worm their way into doing surgeries if the job description/contract doesn't give them that leeway.

 

[Retrograde_Nail]

Understandable - but wow, still very busy even with that kind of set-up, that's wild

Podiatry: "sometimes we do surgery like F&A ortho, sometimes we don't"
I guess the "good" thing about everybody having adequate formal surgeon training is that, if you are trained as such and can get a surgery-focused job, then that's great and the system works as expected - but if you can't (more likely than you'd think) or you find that you're not about that life, then you can dial it back and pursue the non- or minimal-surgical positions. Same like any other MD/DO surgical specialty. I'd still give a non-surgical podiatrist request a consideration - but I sympathize and say that they really shouldn't worm their way into doing surgeries if the job description/contract doesn't give them that leeway.

At my previous hospital job we placed a job posting for a non surgical podiatrist. Nearly everyone who applied was surgical. Some did fellowships.

 

[Bluecollarmed]

We had a couple hospital employed docs in residency hire an NP. We covered all their cases but it wasn't a clinic we actively covered and they wanted to push some of the post op visits and grunt work to open up more slots for new patients and possible surgical patients. They did end up getting rid of that NP after about 2 years for whatever reason.

I know we talk bad about the job market but as a PP or small group owner what would be the pros of hiring an associate over an NP/PA? I can think of few which is bringing in a surgical pod if you don’t actively do surgery or don’t offer hindfoot cases which is a common thing I saw from friends who joined private groups. Other would be call split if the group has a set schedule and you want to dilute that. Other than that hiring an associate likely costs you more money. As hospital pods, we definitely don’t want another pod around. NPs easily take some of the post op visits and run of the mill nonsurgical patients off our schedule.

 

[Hybrocure]

You forget that NPs were all RNs. Cutting people’s toenails is nothing to them (in terms of monotony or level of “gross”). I think if they get paid well based on the local market for their services, and you give them autonomy to treat the patients/pathology you’ve deemed NP-worthy, a podiatry group wouldn’t have any more or less difficulty keeping an NP than any other clinic.

99% of nurses think feet are the grossest part of the body.

They’ll place a catheter or dig in an ass before they’ll take the socks off our usual patient. Believe you me.

 

[Feli]

... as a PP or small group owner what would be the pros of hiring an associate over an NP/PA? ...

Don't have to train DPM associate much/any.
Does better work (you see what you know).
Patients won't complain and say they "want to see the doc."
Knows the podiatry terminology, dx, path, insruments, etc.
Knows how to do procedures (ingrown, injects, warts, many).
Knows how to read imaging films (not just reports).
Unlikely to mess up office ordering wrong supplies.
Salary is similar.
Benefits are less.
Reimburse is same/better.
EMR license, supplies, space, support staff etc is same cost for more capability.
Can take call.
Can cover vacation in full capacity.
Can do biomech stuff (DME, offload surg, etc).
Can do surgery.
Can teach owner occasional things from CME and different training.
Associate undersands OTC.
Can do full Rx (NPs can in some places... not typically).
Won't find podiatry RFC, wounds, etc "gross" as they did it in training.
More likely retention as they try for boards.
More likely retention as they pay down student loans.
More likely retention as they don't have as many job options/locations as NP would.
Possible partnership down the line.
Possible buyout down the line.

There are a lot of advantages. The podiatry associate is done with training... the NP is a permanent first year resident (maybe).

I think the hiring NP is mainly just an avoidance of competiion thing... serously. That not a bad thing. Very smart in some areas/setups. It must be weighed... esp if non-competes don't hold up for medical in the area [I nixed partner/associate plans largely for this reason].

But if NP makes $125k base or whatever is competitive (wouldn't be competitive NP pay to attract - much less keep - one in my area, but maybe in some).. and then NP also want good health/dent insurance, 401k match, other stuff they'd get from hospital or MSG job. At that point, you are at pod associate pay grade ($150-200k and then 30-40%). It's not much difference for the many advantages you get with much higher trained DPM vs midlevel who probably knows very little of podiatry and has inherent limitations. Do you want to have the NP sit there and watch you do ingrowns, heel injects, ankle injects, biopsy, orthotics... pay them for all that? Time is $$ in PP.

For hospital podiatrist, sure: NP/PA is the pick... do more surgery, send them post ops and wounds and RFC, don't introduce competition for cases or refers. You want that 'permanent resident' to work under you. If they quit, not your problem. If they take awhile to learn stuff or don't catch on well, you are not paying them to shadow you. No brainer.

For podiatry PP, I am not sure I see it. For MD/DOs in PP where the NP is only a third the cost of an associate, yes... have both docs and midlevels. But for podiatry with NP about same cost or only 10-20% higher total costs than an associate DPM, dunno. Most pod PPs, and supergroups, choose associates and will continue to. The NP will need much training time and cost, might not stay... not sure it's worth that just to try to save 20% or less (unless you really REALLY don't want potential competition?).

Individual decision for each office/doc at the end of the day, but I'd be slanted heavily to DPM associate (but no point... not necessary to have either one imo, not needed to win the game).

 

[Adam Smasher]

For podiatry PP, I am not sure I see it. For MD/DOs in PP where the NP is only a third the cost of an associate, yes... have both docs and midlevels. But for podiatry with NP about same cost or only 10-20% higher total costs than an associate DPM, dunno. Most pod PPs, and supergroups, choose associates and will continue to. The NP will need much training time and cost, might not stay... not sure it's worth that just to try to save 20% or less (unless you really REALLY don't want potential competition?).

I wanted to write a more thoughtful response to the question "why DPM associate vs NP." Ultimately it's about getting the right person for the jobs that you need done.

As an owner, I have a pretty good understanding of what services are in demand from the community from me and my practice. If I had a heavy surgical referral base or even a lot of non-operative sports medicine/MSK pathology, I think a NP would be a bad fit. I would want to onboard someone with the knowledge base, training, and experience to tackle these problems. Instead, what I'm facing is legions of elderly diabetics with very straightforward complaints. Hiring a DPM to do that is like purchasing a Jeep when the only offroading you ever do is when you accidently drive over the curb.

Another way of looking at it is imagine a solo DPM working at maximum capacity generating $500k/year collections. (just picking an easy number for math reasons). But say there's $800k worth of work out there in this community. Hiring another DPM would allow the practice to generate all $800k of that potential work, but the production per DPM decreases from $500 to $400. This may be fine in the short run if the associate DPM is being paid badly, but it's not a stable working arrangement.

The why would the NP stay? question is valid. I would counter why would an associate DPM stay? Yeah, the work is boring and unglamorous, and that's true irrespective of if you are a DPM or NP. That's why it's called "work" and not "fun." That's why on a personal level, I try not to think of myself as a "podiatrist" but reflect on other dimensions of my life that bring me happiness and fulfillment, and podiatry is just the work I do to support those pursuits. The difference is the DPM is more likely to get restless if their surgical referrals don't materialize. If the argument is to hire an associate DPM and pay them badly, the arrangement is not going to last. If they stay because they are prisoners of a bad job market and the owner's lousy compensation package is the best they can ever do, the best thing you can hope for is a tense workplace culture with proletariat-vs-bourgeoisie resentment building. So if nothing else you should want to keep your associate fat and happy, because replacing associates is not as simple as hiring someone new, the licensing and credentialling process takes months and it's an inconvenient cashflow disruption. And I think it's cheaper to keep a NP fat and happy.

The other way to force your associate to stay is to partner with them. But partnering with the wrong person is almost as bad as marrying the wrong person. There are a lot of things about being an owner that truly do suck, and if your partner won't co-own the suckage, it's a massive albatross around your neck. Ask me how I know. There's a truism out there that "not everyone is meant to be a surgeon." And it's sure as hell true also that not everyone is meant to own a business. It's one thing to say "I will pay you to trim toenails in my office." It's another thing entirely to say "I want to spend the rest of my career co-owning my business with this person, no matter how lazy they may shape up to be and how much my income and home life may suffer as a result."

Bottom line: for the NP, all I need to do is pay her market rate, give her flexibility and autonomy, and ensure patients don't stress her out with their inanity. An associate DPM can easily grow into a monster I can't control, especially if it's one with a big ego and a bad work ethic.