How would you choose between these 2 jobs?

[Nate103]

Hello,
I'm a current pain fellow at an east coast program. I'm still looking for jobs and it's definitely been a bit of a challenge in the market.
I have 2 offers that I'm considering, they're both 100% pain private practice. The first offer is east coast, joining a group of 2 other docs, in a practice that has been around for about 10 years.
They have in-office c-arm, ultrasound, and access to an ASC. They do bread and butter pain as well as some SCS, DRG, and regen medicine like PRP and stem cell injections. It sounds like a great gig for expanding my skill set except their salary offer is quite low, like 100K below median MGMA for pain mgmt for east coast practices, (200K below mean MGMA), no revenue bonus.

The second offer is joining a multispecialty group in a mid-sized midwestern city as the solo pain doc in their group since their pain guy recently left. This one would pay almost 100K more than the other offer in base salary after sign on bonus is included, and there's a possible revenue bonus too. The thing with this practice is however, they don't have spine surgeons or ortho in their group, it's mainly internal medicine and medical subspecialties. I will get 2 ASC days/week depending on my volume, with procedures done at ASC.

My predicament is, while the second practice obviously pays a lot more in a place with a lower cost of living, I'm worried that if I am part of a multispecialty group without ortho or spine, I will end up doing a lot of medication management and not as many interventions as I would like, even though I have those ASC days. On the other hand, it may be an opportunity to build up the practice the way I want since I'll be the sole pain physician.

My second concern is that I would like to eventually use therapies in my practice like spinal cord stimulation and regenerative medicine since I have learned them in fellowship. I'm worried that if I join the second practice that doesn't have these therapies, I may lose the momentum and skill from doing implants and SCS that I gained during fellowship, since it'll take some time to bring those therapies to the multispecialty group as opposed to just bread and butter stuff.

From the experience of you guys who have been in practice several years, is it reasonable to go for the higher paying position and assume that it's not too hard to build up implanting or SCS skills later if I want to? Or is additional mentorship in things like SCS, implanting, and setting up regenerative medicine worth it for the pay cut if I do want to use those treatments in my practice? I appreciate any guidance, thank you.

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[244913]

Hello,
I'm a current pain fellow at an east coast program. I'm still looking for jobs and it's definitely been a bit of a challenge in the market.
I have 2 offers that I'm considering, they're both 100% pain private practice. The first offer is east coast, joining a group of 2 other docs, in a practice that has been around for about 10 years.
They have in-office c-arm, ultrasound, and access to an ASC. They do bread and butter pain as well as some SCS, DRG, and regen medicine like PRP and stem cell injections. It sounds like a great gig for expanding my skill set except their salary offer is quite low, like 100K below median MGMA for pain mgmt for east coast practices, (200K below mean MGMA), no revenue bonus.

The second offer is joining a multispecialty group in a mid-sized midwestern city as the solo pain doc in their group since their pain guy recently left. This one would pay almost 100K more than the other offer in base salary after sign on bonus is included, and there's a possible revenue bonus too. The thing with this practice is however, they don't have spine surgeons or ortho in their group, it's mainly internal medicine and medical subspecialties. I will get 2 ASC days/week depending on my volume, with procedures done at ASC.

My predicament is, while the second practice obviously pays a lot more in a place with a lower cost of living, I'm worried that if I am part of a multispecialty group without ortho or spine, I will end up doing a lot of medication management and not as many interventions as I would like, even though I have those ASC days. On the other hand, it may be an opportunity to build up the practice the way I want since I'll be the sole pain physician.

My second concern is that I would like to eventually use therapies in my practice like spinal cord stimulation and regenerative medicine since I have learned them in fellowship. I'm worried that if I join the second practice that doesn't have these therapies, I may lose the momentum and skill from doing implants and SCS that I gained during fellowship, since it'll take some time to bring those therapies to the multispecialty group as opposed to just bread and butter stuff.

From the experience of you guys who have been in practice several years, is it reasonable to go for the higher paying position and assume that it's not too hard to build up implanting or SCS skills later if I want to? Or is additional mentorship in things like SCS, implanting, and setting up regenerative medicine worth it for the pay cut if I do want to use those treatments in my practice? I appreciate any guidance, thank you.

#2 sounds good. You'll get some nice referrals from PCP's. You can help them manage and taper some of their patients and earn a lot of credibility. The SCS candidates will be there for you.

Why would you want to be the cabana boy for an ortho spine or NSGY group?

How many implants did you do in fellowship

- ex 61N

 

[BobBarker]

It won’t take anytime to start offering SCS, other than you saying today is the day. I don’t really understand your line of thinking.

 

[Disciple]

Hello,
I'm a current pain fellow at an east coast program. I'm still looking for jobs and it's definitely been a bit of a challenge in the market.
I have 2 offers that I'm considering, they're both 100% pain private practice. The first offer is east coast, joining a group of 2 other docs, in a practice that has been around for about 10 years.
They have in-office c-arm, ultrasound, and access to an ASC. They do bread and butter pain as well as some SCS, DRG, and regen medicine like PRP and stem cell injections. It sounds like a great gig for expanding my skill set except their salary offer is quite low, like 100K below median MGMA for pain mgmt for east coast practices, (200K below mean MGMA), no revenue bonus.

The second offer is joining a multispecialty group in a mid-sized midwestern city as the solo pain doc in their group since their pain guy recently left. This one would pay almost 100K more than the other offer in base salary after sign on bonus is included, and there's a possible revenue bonus too. The thing with this practice is however, they don't have spine surgeons or ortho in their group, it's mainly internal medicine and medical subspecialties. I will get 2 ASC days/week depending on my volume, with procedures done at ASC.

My predicament is, while the second practice obviously pays a lot more in a place with a lower cost of living, I'm worried that if I am part of a multispecialty group without ortho or spine, I will end up doing a lot of medication management and not as many interventions as I would like, even though I have those ASC days. On the other hand, it may be an opportunity to build up the practice the way I want since I'll be the sole pain physician.

My second concern is that I would like to eventually use therapies in my practice like spinal cord stimulation and regenerative medicine since I have learned them in fellowship. I'm worried that if I join the second practice that doesn't have these therapies, I may lose the momentum and skill from doing implants and SCS that I gained during fellowship, since it'll take some time to bring those therapies to the multispecialty group as opposed to just bread and butter stuff.

From the experience of you guys who have been in practice several years, is it reasonable to go for the higher paying position and assume that it's not too hard to build up implanting or SCS skills later if I want to? Or is additional mentorship in things like SCS, implanting, and setting up regenerative medicine worth it for the pay cut if I do want to use those treatments in my practice? I appreciate any guidance, thank you.

For clarification, is offer #1 from an Ortho or Spine surgical group?

 

[Nate103]

Thanks for the replies so far. I appreciate the perspective of you guys with a lot more experience than me.

For clarification, is offer #1 from an Ortho or Spine surgical group?

It's actually not an ortho/spine group, it's an independent practice with 2 pain physicians, even though they do a lot of stimulation (from what they tell me) and are getting into regenerative med. When I shadowed, it was quite ethical in the sense that they spent a good amount of time with patients, didn't rush them, did procedures with proper technique. Kind of what attracts me to it despite the lower salary.

#2 sounds good.

How many implants did you do in fellowship
- ex 61N

About 5 so far, probably will do another 3-5 by the end of the year. Maybe about 15 trials.

That is a bit of an unknown for me in the position of a fresh grad; do you think it would be reasonable to start doing trials+implant on your own if you're the solo pain guy for a group and starting out? From where I am now, I would like to have some mentorship from senior partners when doing my first independent implant.
But, if from your guys' experience, if it's possible to get that kind of experience and backup when independent, either from just networking with other surgeons in the area or asking your device rep to hook you up with extra training, then maybe I'm overblowing the benefit of having some mentorship since I'm still just a fellow. Thoughts?

 

[nvrsumr]

In today’s market offer two is better. You will be the gatekeeper to outside referrals from this pcp group to the local ortho and spine if you set yourself up right. Good luck

 

[Dr. Ice]

Hello,
I'm a current pain fellow at an east coast program. I'm still looking for jobs and it's definitely been a bit of a challenge in the market.
I have 2 offers that I'm considering, they're both 100% pain private practice. The first offer is east coast, joining a group of 2 other docs, in a practice that has been around for about 10 years.
They have in-office c-arm, ultrasound, and access to an ASC. They do bread and butter pain as well as some SCS, DRG, and regen medicine like PRP and stem cell injections. It sounds like a great gig for expanding my skill set except their salary offer is quite low, like 100K below median MGMA for pain mgmt for east coast practices, (200K below mean MGMA), no revenue bonus.

The second offer is joining a multispecialty group in a mid-sized midwestern city as the solo pain doc in their group since their pain guy recently left. This one would pay almost 100K more than the other offer in base salary after sign on bonus is included, and there's a possible revenue bonus too. The thing with this practice is however, they don't have spine surgeons or ortho in their group, it's mainly internal medicine and medical subspecialties. I will get 2 ASC days/week depending on my volume, with procedures done at ASC.

My predicament is, while the second practice obviously pays a lot more in a place with a lower cost of living, I'm worried that if I am part of a multispecialty group without ortho or spine, I will end up doing a lot of medication management and not as many interventions as I would like, even though I have those ASC days. On the other hand, it may be an opportunity to build up the practice the way I want since I'll be the sole pain physician.

My second concern is that I would like to eventually use therapies in my practice like spinal cord stimulation and regenerative medicine since I have learned them in fellowship. I'm worried that if I join the second practice that doesn't have these therapies, I may lose the momentum and skill from doing implants and SCS that I gained during fellowship, since it'll take some time to bring those therapies to the multispecialty group as opposed to just bread and butter stuff.

From the experience of you guys who have been in practice several years, is it reasonable to go for the higher paying position and assume that it's not too hard to build up implanting or SCS skills later if I want to? Or is additional mentorship in things like SCS, implanting, and setting up regenerative medicine worth it for the pay cut if I do want to use those treatments in my practice? I appreciate any guidance, thank you.

Expect to be raped in northeast in terms of salary. There's too many people offering the same service as you and these practices have their pick of the litter. Where do you really want to live?

 

[BobBarker]

Sounds like you are looking for a super fellowship so offer #1 may be ok for you.

#2 is the best job. I am in a similar deal as that. You will work up the spines and decide which surgeon gets what for all of those PCPs. If you want to refer some implants out and scrub with the surgeon then they shouldn’t have a problem with that.

 

[drusso]

Offer #2.

 

[lobelsteve]

2. All day.

If uncomfortable implanting at end of fellowship, shadow one of us.

 

[geauxg8rs]

2. All day.

If uncomfortable implanting at end of fellowship, shadow one of us.

Which location does your wife want? Pick that one
Don’t worry about anything else

 

[Ducttape]

Only concern about #2 - if such a good gig, why did the prior guy leave?

Get a little more info. Make sure non compete is acceptable. Make sure that you can do your own billing or hire staff to do your billing. Make sure there is additional revenue stream, because below MGMA for part of country that pays well is not good...

 

[244913]

Which location does your wife want? Pick that one
Don’t worry about anything else

Happy King, happy Kingdom

 

[244913]

Thanks for the replies so far. I appreciate the perspective of you guys with a lot more experience than me.


It's actually not an ortho/spine group, it's an independent practice with 2 pain physicians, even though they do a lot of stimulation (from what they tell me) and are getting into regenerative med. When I shadowed, it was quite ethical in the sense that they spent a good amount of time with patients, didn't rush them, did procedures with proper technique. Kind of what attracts me to it despite the lower salary.


About 5 so far, probably will do another 3-5 by the end of the year. Maybe about 15 trials.

That is a bit of an unknown for me in the position of a fresh grad; do you think it would be reasonable to start doing trials+implant on your own if you're the solo pain guy for a group and starting out? From where I am now, I would like to have some mentorship from senior partners when doing my first independent implant.
But, if from your guys' experience, if it's possible to get that kind of experience and backup when independent, either from just networking with other surgeons in the area or asking your device rep to hook you up with extra training, then maybe I'm overblowing the benefit of having some mentorship since I'm still just a fellow. Thoughts?

If you've scrubbed ten by the end of the year, know how to cut, sew and tie and make a pocket you'll be OK. Just make sure you pick good patients starting out. Non smokers, no fat people, relatively good anatomy, HbA1c < 8. Complications happen, but control for the risk factors.

The biggest key is to take your time. Implants are a lot of fun.

As far as practice #1- ethics aren't about how much time they spend with patients or rushing procedures. That should be a given. Look into their prescribing habits. How many of these patients are on opioids? Do they have midlevels prescribing? Do they see followups or do they just see new patients and inject same day? In house UDS etc? They're already planning to rape you in terms of salary. Make sure it's not a pills for shots model esp. if they are pushing regenerative cash procedures.

- ex 61N

 

[hyperalgesia]

I'm worried that if I am part of a multispecialty group without ortho or spine, I will end up doing a lot of medication management and not as many interventions as I would like, even though I have those ASC days. On the other hand, it may be an opportunity to build up the practice the way I want since I'll be the sole pain physician.

This concern needs to be addressed. I would try to get a sense of how much autonomy you will have. Sometimes ortho/spine are the worst offenders of, "This pt needs a lifetime supply of opioids, sending to the pain specialist." In the case of number 2, as the sole pain specialist, no one is there to second guess your policies.

On the SCS, I wouldn't worry about it. Make contact with the local reps and go to workshops when you're ready. And if you really want, find another doc to assist once or twice. It's definitely not worth taking a different job for that. You can also find other docs in the community to send pts on occasion.

 

[SSdoc33]

definitely consider the significant other, if there is one.

people often say "midwest" when they mean "out in the middle of absolute nowhere". what good is 500k if all you can spend it on is looking at cornfields?

if both jobs were in the same place then obviously #2 is better. #2 is better because it isnt a sought-after or desirable locale'.

most docs end up leaving the first practice they join after fellowship anyway, so pick the job that is best for you right now.

 

[Disciple]

Thanks for the replies so far. I appreciate the perspective of you guys with a lot more experience than me.

It's actually not an ortho/spine group, it's an independent practice with 2 pain physicians, even though they do a lot of stimulation (from what they tell me) and are getting into regenerative med. When I shadowed, it was quite ethical in the sense that they spent a good amount of time with patients, didn't rush them, did procedures with proper technique. Kind of what attracts me to it despite the lower salary.

Probably option #2 is a better choice?

I think you should do a little more digging into both groups.

Option #1: Sounds like the bread and butter of the practice is the procedures. It's unlikely that you'll be fed good procedural candidates from the start. It's quite possible that to start out, the patients with bad insurance or in need of deprescribing will be put on your schedule. To start out, you may see 25 patients per day, with 4-5 being good procedural candidates. If you struggle at the onset, you may need to guard against your mindset inadvertently creeping toward offering injections to some poor procedural candidates.

Option #2: There is likely to be a moderate to large deprescribing component here. Initially, you won't have a sense of what dosages patients in this group are on. You will want to try to get a sense as to whether the group in on board with CDC Guidelines, a high threshold for chronic opioid therapy and referring for Addiction treatment not infrequently. You also want to get a sense as to whether the group will be on-board with sending all the patients with sub-acute/degenerative musculoskeletal conditions to you, before sending to Ortho or Neurosurg.

 

[ssmallz]

I would ask more questions about #1. Why is their salary offer so low? Is it bad contracts or are you getting screwed by other partners? Is there potential for partnership? What's the growth opportunity like? Based on the sound of their practice, it seems to be very lucrative, especially if they do a lot regenerative type things. Starting salary is a very small part of what makes a good offer. I would look into #1 more and see if you have some room to negotiate

 

[Nate103]

Hey guys, sorry for being AWOL. I really appreciate everyone's input and support, it's been quite invaluable.

I would ask more questions about #1. Why is their salary offer so low? Is it bad contracts or are you getting screwed by other partners? Is there potential for partnership? What's the growth opportunity like? Based on the sound of their practice, it seems to be very lucrative, especially if they do a lot regenerative type things. Starting salary is a very small part of what makes a good offer. I would look into #1 more and see if you have some room to negotiate

For #1, I'm not sure about getting screwed, because I got a chance to see the books and it seems like the partners don't make that much more, but maybe that's just the way they reported it. Regarding regenerative being more lucrative, that definitely puzzled me too as I was looking into this job. However, it may be that their volume is just not that high, each doctor may do 25-40 procedures per week.
After one year, there is also the offer to buy into a surgery center that is being opened by a colleague of theirs, but that is a bit hard for me to gauge since the center is not officially open yet and thus has no cash flow presently. I think the choice to buy into a surgicenter is a completely different discussion since being pretty new, I just don't know enough about that business side of things.
I'm having a sense the low revenue of group 1 may be possibly due to ortho groups in the area having their own separate pain guys, driving down their patient load.

After reading all your guys' comments, I am leaning more toward #2. I'll say that even though #2 is a midwestern city, there is a decent young professional community there and a growing tech sector, so it would definitely be more than cornfields! The cost of living would be a huge plus too.
However, fiancee would have to quit her job and look for something new there, but that's something we're working on.

Thanks so much for all the comments so far.

 

[Dr. Ice]

Hey guys, sorry for being AWOL. I really appreciate everyone's input and support, it's been quite invaluable.


For #1, I'm not sure about getting screwed, because I got a chance to see the books and it seems like the partners don't make that much more, but maybe that's just the way they reported it. Regarding regenerative being more lucrative, that definitely puzzled me too as I was looking into this job. However, it may be that their volume is just not that high, each doctor may do 25-40 procedures per week.
After one year, there is also the offer to buy into a surgery center that is being opened by a colleague of theirs, but that is a bit hard for me to gauge since the center is not officially open yet and thus has no cash flow presently. I think the choice to buy into a surgicenter is a completely different discussion since being pretty new, I just don't know enough about that business side of things.
I'm having a sense the low revenue of group 1 may be possibly due to ortho groups in the area having their own separate pain guys, driving down their patient load.

After reading all your guys' comments, I am leaning more toward #2. I'll say that even though #2 is a midwestern city, there is a decent young professional community there and a growing tech sector, so it would definitely be more than cornfields! The cost of living would be a huge plus too.
However, fiancee would have to quit her job and look for something new there, but that's something we're working on.

Thanks so much for all the comments so far.

Be weary about promises for asc buy in. That stuff can change rapidly. Where in the northeast is this opp? if you don't mind me asking. The hands that control the asc pot can change their tune based on other people buying in, revenue distribution at the end of the year or monthly, etc.

 

[SSdoc33]

Hey guys, sorry for being AWOL. I really appreciate everyone's input and support, it's been quite invaluable.


For #1, I'm not sure about getting screwed, because I got a chance to see the books and it seems like the partners don't make that much more, but maybe that's just the way they reported it. Regarding regenerative being more lucrative, that definitely puzzled me too as I was looking into this job. However, it may be that their volume is just not that high, each doctor may do 25-40 procedures per week.
After one year, there is also the offer to buy into a surgery center that is being opened by a colleague of theirs, but that is a bit hard for me to gauge since the center is not officially open yet and thus has no cash flow presently. I think the choice to buy into a surgicenter is a completely different discussion since being pretty new, I just don't know enough about that business side of things.
I'm having a sense the low revenue of group 1 may be possibly due to ortho groups in the area having their own separate pain guys, driving down their patient load.

After reading all your guys' comments, I am leaning more toward #2. I'll say that even though #2 is a midwestern city, there is a decent young professional community there and a growing tech sector, so it would definitely be more than cornfields! The cost of living would be a huge plus too.
However, fiancee would have to quit her job and look for something new there, but that's something we're working on.

Thanks so much for all the comments so far.

my wife (fiancee) at the time had to quit her job and move with me to a midwest city. she has 2 masters degrees, but ended up working as a hostess in a restaurant. buyer beware.......

 

[ssmallz]

Hey guys, sorry for being AWOL. I really appreciate everyone's input and support, it's been quite invaluable.


For #1, I'm not sure about getting screwed, because I got a chance to see the books and it seems like the partners don't make that much more, but maybe that's just the way they reported it. Regarding regenerative being more lucrative, that definitely puzzled me too as I was looking into this job. However, it may be that their volume is just not that high, each doctor may do 25-40 procedures per week.
After one year, there is also the offer to buy into a surgery center that is being opened by a colleague of theirs, but that is a bit hard for me to gauge since the center is not officially open yet and thus has no cash flow presently. I think the choice to buy into a surgicenter is a completely different discussion since being pretty new, I just don't know enough about that business side of things.
I'm having a sense the low revenue of group 1 may be possibly due to ortho groups in the area having their own separate pain guys, driving down their patient load.

After reading all your guys' comments, I am leaning more toward #2. I'll say that even though #2 is a midwestern city, there is a decent young professional community there and a growing tech sector, so it would definitely be more than cornfields! The cost of living would be a huge plus too.
However, fiancee would have to quit her job and look for something new there, but that's something we're working on.

Thanks so much for all the comments so far.

Just an FYI, 25-40 procedures/week is A LOT of procedures assuming they're not all TPIs. There's definitely a lot of money flowing through that practice and it's a GIANT red flag if they open their books and the partners aren't making bank. It's either 1) their practice is poorly managed and the overhead is eating it up 2) the contracts are awful and aren't paying anything or 3) the money is being hidden elsewhere off the books

 

[NOSfan]

#1 - No revenue bonus....No take. Also, sounds like the overhead may be high, or shenanigans, if the revenue is high and the 'partners'' pay is low.
#2 - Why did previous MD leave? Ask to see his/her production numbers. Will you have opportunity to buy into ASC? If you have a heavy PCP referral base, which NS/Ortho do they refer to? Who does NS/Ortho refer to currently?