Leave or Stay

[oscardagrouch]

Hello All,

I am currently in my first job, out of residency and I have come to the point where I need to make a decision on whether no nor it is worth staying.

I work for a hospital owned group at one of their outpatient office, which is located a pretty significant distance from the main hospital. I have been here for just over 1 year. The hospital bought the practice I joined just over 2 years ago, and kept the other provider on board, who is now paid by the hospital.

Here is where my dilemma begins. The terms of my contract allows for a guaranteed salary for a period of one year, after which I will be paid on based on my productions, measured through wRVUs. I need to generate about 380 to 390 wRVUs per month to meet to continued to be paid the same amount they guaranteed me. The 1 year mark came and went and I was topping off at 190 wRVUs a month. The group was gracious enough to extend the guarantee for another 6 months (I was told that they have done this for others in the past).

Part of my problem is that I am not busy enough to keep my current salary when the extension runs out in about 5 months. I'm still not seeing near enough patients. Last month I generated about 200 wRVUs.

I have been going along with the group's plan for marketing me (with some exceptions, like being a chili contest judge) which includes flyers, mailers, local newpaper articles, writing articles, and going to local community fairs. Not much pans out from these.

I have been thinking about giving them my 3 months notice that I will end my contract with them to coincide with the end of the salary extension. Some of the other terms of the contract that have made me think twice about doing this including having to pay back the sign on bonus ( the term of accepting the bonus states that I need to work for them for 3 years. It's 10k, but if I leave at the end of the extension period, I will have to pay them back 5k.)

Other restrictive terms include not working for any other hospitals in the area, and within 10 miles from my current location (thankfully not from any other sites or the main hospital)

Do you think it is worth talking to them about a plan if business does not pick up for me within the next 5 months? Should this talk occur now?

Any suggestions would be great. Thanks.

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[smq123]

Some questions:
1. Do you like this job otherwise? Do you like the staff, the patients, the job responsibilities? Is it convenient to get to? How onerous would a 10 mile restrictive covenant be for you - i.e. do you live in Los Angeles, where it can take an hour to travel 10 miles?

2. Do you have any thoughts as to why you are not generating enough RVUs? Do you not bring your patients back at regular intervals? Do you feel like the patients like you and you are developing a rapport? Are you seeing a lot of new patients? Or you do you feel that the community does not support another full time doctor?

I imagine that the group is anxious to keep you, and it shows - I mean, a chili contest judge? That speaks to a certain level of desperation, I feel.

 

[JustPlainBill]

So, having been there, done that -- a few questions: Is this in the boonies? Did you research it enough to determine that the need for another provider was there? Usually takes about 4-8K people to support an FM doc in a community. Now the real question is: Of the payor mix, how many are seeking new docs in the local area vs how many are going one town over to the "better" hospital system? Had that happen to me. Also, got news for you -- it usually takes about 18 months to 2 years to establish a practice and make it profitable including your salary. Food for thought. With them having you be a chili cookoff contest judge, I think I know what the real problem is --- this hospital wanted a new doc for peanuts because you represent revenue through your admissions/ancillaries with very low overhead. They know they can bully you into feeling guilty about your lack of wRVUs and work harder since you have no experience. The more senior physician likely already has his patient base set up and is on cruise mode. For me -- I'd consider leaving a hospital based system and trying to join a private practice that's willing to take a chance on you. If you've graduated residency and are board certified, you've got the right stuff -- all you need is experience.

Again, ymmv, no warranties expressed or implied, advice is worth what it cost you. Good luck

 

[Bacchus]

Is it just me (to tack onto this conversation) or is that an inappropriate amount of wRVUs expected? That's about 4500 a year. I think at my system after one year guarantee is gone, they're looking for 3500 wRVUs.

 

[deleted87716]

Sadly, this is typical behavior for a hospital system. You didn't say what your salary guarantee is, but I'm guessing it's pretty high. They'll do that to entice you to take the job, knowing full well that you'll have to bust your butt to keep making that much once the guarantee period is over.

Agree with the other posters that building a practice from scratch usually takes much longer than one year (my group offers three-year guarantees).

That being said, I'd look at the volume trend. If you're continuing to build your practice as opposed to stagnating, consider hanging in there. You'll take a pay cut for a while, but it may be worth it in the end if you like the job and location otherwise. Also, consider asking the hospital to extend your guarantee for a year rather than six months. They'll probably do it if they don't want you to leave.

I can't comment on whether or not the wRVU expectation is realistic, as I've never been paid that way.

 

[galactus]

Is it just me (to tack onto this conversation) or is that an inappropriate amount of wRVUs expected? That's about 4500 a year. I think at my system after one year guarantee is gone, they're looking for 3500 wRVUs.

Wow such low targets! My first year out of training I was expected to hit 5600 wRVU. I probably had 190 wRVU my first month, but afterwards I was generating 350-500 wVU/month.

 

[cabinbuilder]

Dang. I see about 20 pts a day avg in urgent care and my monthly threshold for RVU's is 312 avg per month each quarter. I am currently hitting 400-450 RVU's a month without even trying and that's working 14 days a month. Are you coding all your charts correctly? Are you doing shots, Nebs, IZ's, trigger points, joint injections, ear lavage, etc. Easy stuff but if you don't code it right it's money out the door. Maybe you need to sit down with the coders/billers and see if there is something you are not doing? Also, what is your daily volume like? Are you only seeing 5 people a day, or 20?

 

[oscardagrouch]

Thank you everyone for your input.

Here is some more info. The guarantee is 170k for a period of 1 year and added an additional 85k to cover me for the next 6 months. I also do some moonlighting within the hospital system, covering 3 night shifts at their LTAC for $70 per hour (9 hour shifts) per month. All of the doctors in the group work 4.5 days per week, myself included. A doctor at another office is out on sick leave, and they offered to pay me $400 extra per week to cover an afternoon once a week (on my half day). Part of their reason for offering this to me first is that they believe that I could pick up some more patients and potentially bring them back to my office.

As far as the location, yes it is in the boonies. What actually lead me to take this job is one of my classmates from medical school works for the group, and his office is about 2 miles away from mine. I reached out to him while I was looking for a job (I relocated here to the South from the North East) and was told that it's a pretty good group to work for. When I was corresponding with said classmate, he was still within his first year and on the guarantee. He told me that he is super busy and have been earning over 400 wRVUs a month after about 6 month on the job. Sounded great to me.

The group has also signed me up for Zocdoc, to help drive in new patients, and I get about 2-3 new patients out of that now. A lot of my repeat patients use it to schedule themselves. I have a 4.8/5 rating with about 30 reviews. I have decent reviews online as well, including on Google reviews, WebMD and Healthgrades. I know what you are think, that I had family members do it for me, but no, I do not. Scout's Honor. Plus, the Zocdoc reviews are sent to patients by Zocdoc themselves after the visits, so those are reliable reviews and outsiders cannot add reviews. I understand how important customer service is in our line of work.

Now, here is where it becomes a bit sticky. My front office lady is from this area, and she told me one day that part of the reason I'm having such a difficult time is that there is a high level of ignorance in the area. We are about 17 miles from the center of a medium sized city in the South. I started believing this when I started overhearing some of the things patients would ask the ladies at the front desk. Some of the gems include " who's that black guy sitting in the corner?" (I'm not black, I'm indian), "oh, he's a doctor? I thought he was the IT guy" and my personal favorite " "why is his name _______? what is his real name? " (I have a common American first name, and an Indian last name)

I don't want to leave this group as they really do treat their physicians well. The VP of the group, who is also a family doc told me that they are committed to making it work at this practice and that they are committed to waiting it out. He is a pretty trustworthy guy and has never gone back on his word so far. Also, I have a pretty good thing going with the moonlighting opportunities, as I was searching for months and months for some moonlighting opportunities when I first moved down here.

As for the billing aspect, I have gotten a lot better at it, and bill as best I can. I ask my office partner for help when I'm unsure.

I think I will approach him as we get closer to the end of the year and talk about extending my salary for another 6 months. I figure that I can use all of my good online reviews as evidence that I provide great care to patients. If they are not willing to extend my salary for a few more months, then I will have to see where I am at with my volume to determine whether or not it may work out.

Any thoughts?

 

[Merely]

170k in the boonies!? That's low low low! Am I missing something here? I can't wait for the attendings to chime in this seems strange...how is 170k a guarantee? That seems like so low lol

 

[deleted87716]

170k in the boonies!? That's low low low! Am I missing something here? I can't wait for the attendings to chime in this seems strange...how is 170k a guarantee? That seems like so low lol

Not for outpatient-only.

 

[Bacchus]

Not what you're asking about, but $70 an hour for your extra work seems really low...like lower end of resident moonlighting low. And, $400 to cover a full half day? That seems low as well. Our network was offering $140/hr to cover another office a half day a week.

 

[deleted87716]

Not what you're asking about, but $70 an hour for your extra work seems really low...like lower end of resident moonlighting low. And, $400 to cover a full half day? That seems low as well. Our network was offering $140/hr to cover another office a half day a week.

$70 is on the low side. Our group pays $120/hr. to work an after-hours clinic. If it were much less, I doubt anyone would want to do it.

 

[Freezeout]

Seemed low to me as well. I'm a resident and get a good deal over that for similar coverage at our hospital.

 

[Merely]

Not for outpatient-only.

But its a bad location? In that other thread people were getting 250k base offers for horrible locations like that and like 200k for decent locations. Damn, I really hope sub-200k offers are not the norm that would be very depressing! But given that they are paying him horribly for other things like the extra coverage and moonlighting I feel like his location just sucks for pay in general.

 

[smq123]

170k in the boonies!? That's low low low! Am I missing something here? I can't wait for the attendings to chime in this seems strange...how is 170k a guarantee? That seems like so low lol

Not for outpatient-only.

I disagree; I feel like 170K for a not-very-desirable location is on the low side. I've seen offers to new graduates in the 180s in my old city, which is a moderately sized city on the Gulf Coast of Florida - i.e. a very desirable location that had no trouble attracting physicians.

 

[deleted87716]

Well, you have to balance "not very desirable" (which is subjective) with cost of living (not subjective), which is usually much better in the boonies than the city.

 

[cabinbuilder]

$70 is on the low side. Our group pays $120/hr. to work an after-hours clinic. If it were much less, I doubt anyone would want to do it.

$70/hr is lower than locums rate with all expenses paid. My guarantee in urgent care is 243K. We work extra shifts for $115/hr. Most locum hospitalists are getting $165/hr for inpatient work. $70/hr is less than what a PA makes. Something is very wrong with that contract.

 

[oscardagrouch]

Thanks again for your input.

It is somewhat of a rural area, but not terribly far from civilization. It take about 30-40 mins to drive to the hospital campus which is located in the major city (local roads, no highway) I thought at the time I signed on the salary was fair. I am not sure where the boonies/salary line begins, but I feel like it would be much further away from where I work.

I get paid $400 for the afternoon shift, and that is 4 hours long, so $100 an hour. I am not contented with the pay for the night job covering the LTAC, because at $70 an hour, it's not worth it when you are getting harassed by nurses calling to ask silly questions like " the patient's bp is 130/60, is that too low" and "what's the difference between a foley and a texas cathether?" Plus, you have to take care of ICU patients. The sad part about that job? All of the other doctors who are covering the shifts are attendings. No residents. One of the doctor is a sub-specialist at the big name university hospital in town. I have considered stop working at the LTAC, but I don't have another job to take it's place.

I found it extremely hard to find moonlighting jobs in this area, and so I took whatever came my way. I did find other opportunities that are about an hour away in what I condiser to be the boonies, but they want you to function as a hospitalist and ER doc at the same time as you will be covering both. I can handle the hospitalist part, no problem, but I do not have enough experience to man an ED by myself.

The intended salary for my daytime outpatient job is 205k at 400 wRVUs per month. We are paid over $43 per wRVU. Even if I were hitting the mark every month, and making that amount per year, I feel like it is a fair amount of money for the work unless everyone else thinks it too low for the area.

How does everyone feeling about me approaching them in a month or two to talk about extending the guarantee? Do you think trying to use my positive reviews as a bargaining chip is worth it?

 

[JustPlainBill]

Thank you everyone for your input.

... I started believing this when I started overhearing some of the things patients would ask the ladies at the front desk. Some of the gems include " who's that black guy sitting in the corner?" (I'm not black, I'm indian), "oh, he's a doctor? I thought he was the IT guy" and my personal favorite " "why is his name _______? what is his real name? " (I have a common American first name, and an Indian last name)
...

Any thoughts?

Ok, now you have just been pitched a softball that you can really have a good time with --- spread the rumor that your "American" name is -- and use your real name. Then spread the rumor that your real given name is something like ---

Owatagoo Siam (say it fast -- turns out to be O What a Goose I am) or Heywoodja Blowme -- or something along those lines -- you can get really creative and have a good laugh....

but that's just me -- I've got a friend and residency colleague who's tribal name is extremely difficult to spell, much less pronounce in English --- during the week before residency kicked off, someone asked him about his "real" name -- when he spelled it and said it he quickly followed it up with --- "but I go by Nicholas" -- and Nicholas it was the entire time.... we still laugh about that one....

 

[oscardagrouch]

Ok, now you have just been pitched a softball that you can really have a good time with --- spread the rumor that your "American" name is -- and use your real name. Then spread the rumor that your real given name is something like ---

Owatagoo Siam (say it fast -- turns out to be O What a Goose I am) or Heywoodja Blowme -- or something along those lines -- you can get really creative and have a good laugh....

but that's just me -- I've got a friend and residency colleague who's tribal name is extremely difficult to spell, much less pronounce in English --- during the week before residency kicked off, someone asked him about his "real" name -- when he spelled it and said it he quickly followed it up with --- "but I go by Nicholas" -- and Nicholas it was the entire time.... we still laugh about that one....

I don't have a tribal name, and I don't mean that type of "Indian"...think dot, not feather. I don't have any other name.

 

[JustPlainBill]

I don't have a tribal name, and I don't mean that type of "Indian"...think dot, not feather. I don't have any other name.

Sorry -- see how my post is easily confused -- I did take it that you were dot, not feather. My colleague was from Africa hence my use of "tribal" -- during one of our conversations he did comment that his tribe was known for business, real estate and cattle farming and they were quite good at it.

I was trying to be humorous and obviously failed --

 

[Goro]

You guys are probably way too young to remember this, but from Saturday Night Live, "Havnagudtyme Vishnuverheer"

Ok, now you have just been pitched a softball that you can really have a good time with --- spread the rumor that your "American" name is -- and use your real name. Then spread the rumor that your real given name is something like ---

Owatagoo Siam (say it fast -- turns out to be O What a Goose I am) or Heywoodja Blowme -- or something along those lines -- you can get really creative and have a good laugh....

but that's just me -- I've got a friend and residency colleague who's tribal name is extremely difficult to spell, much less pronounce in English --- during the week before residency kicked off, someone asked him about his "real" name -- when he spelled it and said it he quickly followed it up with --- "but I go by Nicholas" -- and Nicholas it was the entire time.... we still laugh about that one....

 

[JustPlainBill]

You guys are probably way too young to remember this, but from Saturday Night Live, "Havnagudtyme Vishnuverheer"

Don't recall that one but I do remember Samurai Deli with the quote," I see you are a Master Baker".....

 

[smq123]

How does everyone feeling about me approaching them in a month or two to talk about extending the guarantee? Do you think trying to use my positive reviews as a bargaining chip is worth it?

I don't think that it hurts to ask to extend the guarantee. But I don't think that your positive reviews are a very useful bargaining chip. Because while we would like to believe that hospital administrators value physicians who deliver good care and have good patient relationships, at the end of the day, they would probably prefer to have someone who has a 3 star rating, but sees 30 patients a day, over someone who has a 5 star rating, and only sees 12.