My experience finding a job in PP

[blasthardcheese]

Hello all. I’m a long-time lurker and now first-year attending in private practice. This forum has been extremely helpful in the past, so I have finally decided to join and share my experiences and tips for finding a job after residency.

First, use the search function and read as many threads on this site as you can. There is a lot of valuable info here and the more you read, the easier is to figure out who is a reliable source info and who isn’t. Also, I’m going to do my best to keep my post unique and not duplicate too much of what’s been discussed in other threads.

Second, this thread focuses on private practice employment and assumes hospital/ortho/MSG jobs are desirable will treat you fairly. I didn’t interview with too many of these places and don’t have too much knowledge to pass on. Of note, I did talk with three separate hospital systems who had retiring podiatrists who the hospital decided not to replace. Two of the hospitals were places I trained and I knew the retiring doctors well. With all the talk on this forum about how much money podiatrists make a hospital, I found it strange three hospitals didn’t want to replace the retiring docs. I suspect my experience is not the norm though.

Third, a lot of finding a good job is dumb luck. A good job has to be out there for you to get it and you have to be applying a just the right time.

Enough background, onto the tips
When to start looking for a job: Now. It doesn’t matter what year you are. Earlier is better. “Give us a call back in 6 months” is better to hear than “We just hired someone”. Also, you never know who knows someone who is looking for an associate and can pass your name along. Be nice to the docs, nurses, reps, etc., as they may know someone who can help you.

Where to look: Everywhere. Don’t be bound by location and limit yourself to a few offers. You need as many offers as you can get to increase your odds of getting a good job.

How much will I make: There are enough threads about this. Read those. Also, know how much stuff pays. Look up the Medicare fee schedule. Know how much common codes like 99213/99203 11721 11042 pay. Also, read the surveys. I have included some links to podiatry surveys. Take them with a grain of salt. I think the ACFAS survey does the best job of breaking up the data into groups to give you a better idea of who makes what.

Helpful links (may need to be a member to view some):
ACFAS Compensation and benefits survey 2018: Sign In
APMA Podiatric Practice Survey 2018: 2018 Podiatric Practice Survey | Surveys and Studies | Practicing DPMs | APMA
PM News Annual Survey 2018: Podiatry Management Online
MGMA is also good if you have access.

What to do: Make a good resume and cover letter. Send them to every place you want a job and any place you would even consider working. Call. Email. Talk to the HR person/hospital recruiter. My cold call response rate to even hear back at all was about 1 in 10, which really isn’t bad. Once you have a solid resume and cover letter set up, the time cost is minimal to send it out.

Other helpful websites:
RVUs and how to market yourself to hospitals: https://apma.files.cms-plus.com/Fil...n APMA PM Expo_Handout - Jacob Wynes, DPM.pdf
Help for the job search: Life After Residency / Job Search (This site is GOLD. There are tons of links and tips to basically walk you through the whole process of finding a job. I used this site a ton.)

Experiences:
Don’t expect to hear back from most places you cold call. If they’re not interested, they will just ignore you. The only exception is hospital physician recruiters, who tended to be helpful and friendly, even if the hospital wasn’t looking for anyone.
I was more surprised at the number of practices who ghosted me after an initial interview (and one place ghosted me after an in-person interview). I felt like I at least deserved the courtesy of being told I wasn’t a good fit, but whatever. A place that doesn’t call you back isn’t a place you want to work anyway.
On that note, I was also surprised at the number of places who asked inappropriate interview questions. Are you married? Do you have kids? Do you go to church? Like, these places didn’t even do the typical, open ended, “tell me about yourself” question to lure you into giving up personal info, they just straight up asked it. Are you married was the FIRST question I was asked by one practice.

Should I join this practice: First, find out how often they go through associates. Go to the practice website and find the about the doctors page. Plug the URL into the Wayback Machine (Internet Archive: Wayback Machine) to view old versions of that page and see how often the doctors change. If you see a lot of different people come and go, stay away. Also, Google search the text of any online ad and see if an old ad for the same job pops up. A lot of associate mills are lazy and don’t bother to change the text of their ads.

Second, when you shadow the doctor around: look at what they are billing. You should know what the different codes pay (as discussed earlier) so you can keep a mental tally of what they are getting paid for each visit. Look at how much they try to pad the patient’s bill and sell lotions, orthotics, etc., because if they’re selling it, you’ll be expected to sell it too. Make sure the doctor is coding for what he/she is doing and not upcoding to make a few extra bucks. You don’t want to be a part of that.

Third, If the office is “busy”: Every practice trying to hire thinks they are busy, whether they are seeing 30 patients a day or 60. But you need to look at how many staff people there are helping the doctor. I think some doctors get caught in a cycle of needing to see more patients to make more money so they hire more MAs which increases expenses and means they need to see more patients to make more money... Every non-doctor person is only costing the practice money and too many of them drag down the overhead, so it won’t matter how many you see in a day, you’ll still be poor.

Fourth, how many patients will you see in a day? Not how many they “promise” you how many you need to see to make a decent living. You can't make much money if the volume isn't there. And you need to know the practice overhead percentage. When you talk contract they will probably quote you a base + % after amount of collections. Assume you will eventually be paid completely on percentage of collections. If overhead is 70% (a real number I was quoted at one practice), you will probably never make over 25% of what you bring in.

As stated in other threads, a practice should pay for things that are required for your job e.g. license, DEA, malpractice insurance, CME (at least some of it), etc. I wouldn’t consider not having those things on the initial contract a dealbreaker, but if I also wouldn’t sign a contract if you couldn’t get them added in during negotiation.

HAVE A LAWYER READ YOUR CONTRACT. HAVE A LAWYER READ YOUR CONTRACT. HAVE A LAWYER READ YOUR CONTRACT.

Misc experiences from job interviews:

• If some portion of your compensation is a % of money you collected, it is not a “bonus”. I hate when they call it that
• Two (!) places where I interviewed had a cap the bonus. So basically, you reached a point in the year where you just started working for free. No thanks.
• “I know you want the big bucks but I’m the owner only make $xxx,xxx.” The owner can make their salary whatever they want. A lot of things, like automobiles, can be owned/leased or expensed by the practice, negating the need to have that money in the owner’s paycheck.
• “Dr. Lastassociate thought 60k was a lot of money”. Hahahahaha no they didn’t.
• “You’ll need to go out and market yourself” - told to me by the practice MARKETING DIRECTOR. Not quite sure what that person was supposed to do while I was out marketing myself then.
• “We don’t offer health insurance but your spouse will most definitely be able to find a job in (city) and you can just be on their plan”. Yeah, no you can't guarantee that.

TLDR: Apply early, apply often. Get everything in writing. The good jobs are out there but you will have to work to find them.
So how did things turn out for me? Despite all the bad jobs, I found one good one. One month in and I like it. The practice was VERY busy and my schedule is filling up fast. I’m in my second week of seeing patients and I had 17 today and I’m not even on many insurances yet. I’m not micromanaged and not told how certain things have to be billed or forced to push in office products. I have a guaranteed base of 120k and get 30% of collections after 400k collections. Benefits are good too, the practice pays for 100% of my health insurance premiums, has 401k, pays CME, license/DEA, pays for my phone and gives me some gas money/mileage. I’m okay with that percentage being a little low because of the benefits there are enough staff in the office that I pretty much only see patients and write notes and they handle everything else.

If you have any questions ask and I’ll try to answer below or in a PM. Thanks to all the attendings who post on here regularly, I’ve learned a lot from you all.

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[JewOnThis]

Good post. I have had the same experience with some hospitals telling me they don’t make much off us. I actually had a hospital’s CEO interview me and said pods are not profitable.

 

[CutsWithFury]

Good post. I have had the same experience with some hospitals telling me they don’t make much off us. I actually had a hospital’s CEO interview me and said pods are not profitable.

That is a FLAT OUT LIE

 

[deleted1054119]

Good post. I have had the same experience with some hospitals telling me they don’t make much off us. I actually had a hospital’s CEO interview me and said pods are not profitable.

Ignorant CEOs (IGNORing reality) do exist & they typically don’t last very long. How hard is it to look at MGMA pod collections and subtract what they’re paying out to pods in each tier= $$$ ???

2014’s average was $400K after pod was paid. 80th percentile $548K after pod was paid. Hint: this is higher than some MD/DO specialties. Now overhead is spread out across this entire facility and group of all providers. As mentioned in other threads this does not include ancillary or referrals. That’s a pretty good deal for any “CEO” who, by the way, are in the business of impressing their board of trustees and stake holders

 

[JewOnThis]

That is a FLAT OUT LIE

The hospital was in a rural setting. They had A total of 3 ORs , lol.

 

[CutsWithFury]

The hospital was in a rural setting. They had A total of 3 ORs , lol.

A podiatrist can make money in that situation if they have any real talent or training. If it’s that rural they would most likely be better than their competitors in the community. You really need to understand who is practicing around you to understand how successful you could be. That goes for anyone looking for any kind of employment options (ortho/MSG/hospital/private practice).

 

[Shiyuan]

Excellent post.

 

[G0dFather]

I have a guaranteed base of 120k and get 30% of collections after 400k collections. Benefits are good too, the practice pays for 100% of my health insurance premiums, has 401k, pays CME, license/DEA, pays for my phone and gives me some gas money/mileage. I’m okay with that percentage being a little low because of the benefits there are enough staff in the office that I pretty much only see patients and write notes and they handle everything else.

So would you say this is around a 175k package for year one if you can bring in 500k? ... 120K + 30K (collections percentage) + 25K (total cost of benefits) ?

 

[blasthardcheese]

So would you say this is around a 175k package for year one if you can bring in 500k? ... 120K + 30K (collections percentage) + 25K (total cost of benefits) ?

I think that's a fair estimate.

 

[G0dFather]

I think that's a fair estimate.

i guess this what i will start to hire associates with if this is accepted as fair ... i have been struggling with what will be competitive and will make an associate stay on for the long run, this is very doable as long as the patient volume continues to go up

 

[Dochopeful13]

I think that's a fair estimate.

How many years do you think it will take you to get 200k (base plus collections) not including the benefits package?

 

[Sartorius P.O.D.]

Ignorant CEOs (IGNORing reality) do exist & they typically don’t last very long. How hard is it to look at MGMA pod collections and subtract what they’re paying out to pods in each tier= $$$ ???

2014’s average was $400K after pod was paid. 80th percentile $548K after pod was paid. Hint: this is higher than some MD/DO specialties. Now overhead is spread out across this entire facility and group of all providers. As mentioned in other threads this does not include ancillary or referrals. That’s a pretty good deal for any “CEO” who, by the way, are in the business of impressing their board of trustees and stake holders

It has been mentioned before a but bears repeating that a large part of your value to a hospital/MSG/large ortho group in the downstream revenue you generate. If those entities have imaging, sx centers, or PT you can make them as much or more than what you bill for your services.

 

[heybrother]

Edit: Overly negative rant removed. Chasing downstream revenue can be a sign of not knowing what you are doing. I will continue to assert my negative feelings towards WHCs that generate plenty of expensive downstream care without doing anything that helps the patient.

 

[blasthardcheese]

How many years do you think it will take you to get 200k (base plus collections) not including the benefits package?

Not in my first year, but think I should have it by the end of my second.

Math as follows (with rounding to simplify)
200k net / 30% = 667k gross
667k gross / $85 per visit (trying to pick a reasonable number) = 7847 patient encounters/year
7847 visits/48 weeks = 164 patients per week
164 patients / 4.5 days worked = 36-37 patients a day

The missing half day is a surgery day, which will obviously bring in a little money not accounted for in the above math. There will also be some weekend/evening diabetic foot surgeries, but that's probably not going to make much of a difference in the above numbers. (Also, assuming a half day of surgery every week is a bit of a stretch for me, but makes the math easier)

Limiting factors would be a low patient volume (the practice is busy/growing, and I've inherited the previous associates schedule, so this shouldn't be an issue), and low per patient revenue (harder to control and right now I'm just doing RFC which doesn't bring in a ton to me). Fortunately, I'm getting new patients and the other docs don't play games to keep new patients or good insurance plans.

200k is just a number. I just need to pay my loans, feed my family, and save for retirement, so obviously money does play a big role in job selection, but you need a job where you enjoy what you do and are treated fairly.

ETA: Forgot to mention above, I think I'll hit 40 patients a day consistently in about 3-6 months once I'm on all the insurances, so will be able to get 200k by year two assuming the math above proves true.

 

[blasthardcheese]

Some more thoughts on contracts

Base salary is an indication of how much the practice risk the practice is willing to take on. If they pay you a bigger salary, they believe there is the patient volume for you to see to recoup the cost.

Benefits are the same as base salary eg. this is money they are spending on you that they expect to recoup by you working.

Percentage of collections shows how much money you are getting from the work you and how much the owners are making off of you. Obviously, you have to know what the practice overhead is to to know what the owner is making off of you. And, to be fair, they do have to make some money off of you.

Obviously, the best "contract" would be working for yourself, but carries the most risk.

Also, you can't go around chasing the highest value contract. There were PP contracts where I would have made more money, but didn't feel like the practice was a good fit and/or I would have been billing "creatively" to make good money. Don't be the pod who ends up in PM news for medicare fraud.

A thought on base salary:
Unless your SO has a job in wherever you live for practice, the base salary in your contract will be your only proof of income for landlords when you go to rent an apartment/home. So even though you may know you will make 130k your first year from collections, if your contract says your salary is 80k that guaranteed number is the one a landlord is going to look at and not promised future money.

On that note, rent, don't buy for your first year. You never know how the job is going to go and don't want to get trapped bad job because you can't afford to sell a house. Yes, you will miss out on a year of building equity. Just think of the added cost as paying for the ability to not be trapped.


Misc thoughts:
Home | White Coat Investor - wish I had started reading this site earlier in my podiatry career. I can't recommend this site enough to students and residents.

My situation is kind of unique in that I ended up in a job that could supply me with a lot of patients as soon as I was ready and I am very grateful for that. Strangely, in my other PP interviews, the jobs where I would have replaced an associate that left were the ones that paid the least (I wonder why they left...). The one PP I interviewed at that wanted to add another doctor actually had a very good offer that was probably a higher salary than the job I took. They ended up taking someone else for the job though, but I would have taken that job had they offered it to me.

I'm in big city in the midwest and cost of living is slightly below the national average. My salary isn't artificially high to reflect cost of living.

More PP interview horror stories:
- "We've had 3 associates jump ship for the hospital in town, so you can't do surgery there".
- "We're going to buy another building and expand the practice soon". (Spoiler alert, this hasn't happened yet, and also this practice also hasn't hired an associate. COVID could have played a factor though)
- One of the jobs I applied for a year ago is still posting ads for their job, though they recently increased their base salary 20k above what they offered me
- "Dr. Lastassociate could have made more money, but didn't do enough PADnet"
- "Can you afford to live off of what I would pay you? Some people want to come in and make big bucks and pay off debt fast." (What's wrong with wanting to pay off debt???)

 

[air bud]

Edit: Overly negative rant removed. Chasing downstream revenue can be a sign of not knowing what you are doing. I will continue to assert my negative feelings towards WHCs that generate plenty of expensive downstream care without doing anything that helps the patient.

yeah downstream revenue really grinds my gears. I work techincally for the medical group even though my office is in the hospital. The xray equipment is owned by the hospital. So after they have paid my copay, they often have to pay a hospital copay to get xrays. Then they get an xray. Then they come back to my office. Then I read the xray, treat the patient and they leave. Then the radiologist gets around to reading it. Then they get a bill from the radiologist.

 

[air bud]

Not in my first year, but think I should have it by the end of my second.

Math as follows (with rounding to simplify)
200k net / 30% = 667k gross
667k gross / $85 per visit (trying to pick a reasonable number) = 7847 patient encounters/year
7847 visits/48 weeks = 164 patients per week
164 patients / 4.5 days worked = 36-37 patients a day

The missing half day is a surgery day, which will obviously bring in a little money not accounted for in the above math. There will also be some weekend/evening diabetic foot surgeries, but that's probably not going to make much of a difference in the above numbers. (Also, assuming a half day of surgery every week is a bit of a stretch for me, but makes the math easier)

Limiting factors would be a low patient volume (the practice is busy/growing, and I've inherited the previous associates schedule, so this shouldn't be an issue), and low per patient revenue (harder to control and right now I'm just doing RFC which doesn't bring in a ton to me). Fortunately, I'm getting new patients and the other docs don't play games to keep new patients or good insurance plans.

200k is just a number. I just need to pay my loans, feed my family, and save for retirement, so obviously money does play a big role in job selection, but you need a job where you enjoy what you do and are treated fairly.

ETA: Forgot to mention above, I think I'll hit 40 patients a day consistently in about 3-6 months once I'm on all the insurances, so will be able to get 200k by year two assuming the math above proves true.

if you are seeing 40 patients a day and only making 200 then you are getting ripped off and screwing yourself. And no, as a new grad its not about what you enjoy. Its about getting your loans paid of ASAP. Then you have options and then you can enjoy things.

 

[CutsWithFury]

if you are seeing 40 patients a day and only making 200 then you are getting ripped off and screwing yourself. And no, as a new grad its not about what you enjoy. Its about getting your loans paid of ASAP. Then you have options and then you can enjoy things.

What he said. That’s a ton of work to only make 200k

 

[deleted1061086]

Not in my first year, but think I should have it by the end of my second.

Math as follows (with rounding to simplify)
200k net / 30% = 667k gross
667k gross / $85 per visit (trying to pick a reasonable number) = 7847 patient encounters/year
7847 visits/48 weeks = 164 patients per week
164 patients / 4.5 days worked = 36-37 patients a day

The missing half day is a surgery day, which will obviously bring in a little money not accounted for in the above math. There will also be some weekend/evening diabetic foot surgeries, but that's probably not going to make much of a difference in the above numbers. (Also, assuming a half day of surgery every week is a bit of a stretch for me, but makes the math easier)

Limiting factors would be a low patient volume (the practice is busy/growing, and I've inherited the previous associates schedule, so this shouldn't be an issue), and low per patient revenue (harder to control and right now I'm just doing RFC which doesn't bring in a ton to me). Fortunately, I'm getting new patients and the other docs don't play games to keep new patients or good insurance plans.

200k is just a number. I just need to pay my loans, feed my family, and save for retirement, so obviously money does play a big role in job selection, but you need a job where you enjoy what you do and are treated fairly.

ETA: Forgot to mention above, I think I'll hit 40 patients a day consistently in about 3-6 months once I'm on all the insurances, so will be able to get 200k by year two assuming the math above proves true.

You’re private practice owner is going to love you. If I ever have to see 40 patients a day to make 200k I will retire.

 

[CutsWithFury]

You’re private practice owner is going to love you. If I ever have to see 40 patients a day to make 200k I will retire.

Yup. What's even more ridiculous is that hospital employed DPMs are making 240-275K first year base salary. Possibly more. That doesn't include RVU incentive bonuses and quality care bonuses.

 

[Pronation]

Should I join this practice: First, find out how often they go through associates. Go to the practice website and find the about the doctors page. Plug the URL into the Wayback Machine (Internet Archive: Wayback Machine) to view old versions of that page and see how often the doctors change. If you see a lot of different people come and go, stay away. Also, Google search the text of any online ad and see if an old ad for the same job pops up. A lot of associate mills are lazy and don’t bother to change the text of their ads.

Excellent tip. If an associate is jumping ship every couple years then the business owner is telling you complete lies. Unfortunately this is most private practice podiatry offices. Welcome to the profession.

 

[CutsWithFury]

I just used Internet Archive: Wayback Machine to review a previous private practice podiatry group that changes associates every 3-4 months or so. When I plugged the websites address into the search bar it came up with 46 different snapshots of the website with staff changing from 2011 to current time. Forty-six times. Unbelievable.

 

[619]

Yea 40 patients a day for 4.5 or even 4 days of clinic is how you burn out quickly. Making $200K in W2 income, after taxes, retirement and other deductions, you don't have much left for vacation, hobbies etc. How many years can one sustain seeing 40 patients a day.

A Resident or pod student reading this will say 40 patients a day is not a lot however forget residency where we see twice the number but then again, it's the attending with several residents plus students running the clinic and the residents are doing all the notes. Real life in private practice is different.

 

[josebiwasabi]

I am 1 year into PP.

I see about 25 patients per day, thankfully with a wide variety of pathology. I think I could probably see up to 30 per day and still provide quality care and get my notes done on time and do a good job with documentation.

Not sure how I could consistently do more than 30+ per day unless it included a bunch of routine care type patients.

 

[DYK343]

Yea 40 patients a day for 4.5 or even 4 days of clinic is how you burn out quickly. Making $200K in W2 income, after taxes, retirement and other deductions, you don't have much left for vacation, hobbies etc. How many years can one sustain seeing 40 patients a day.

A Resident or pod student reading this will say 40 patients a day is not a lot however forget residency where we see twice the number but then again, it's the attending with several residents plus students running the clinic and the residents are doing all the notes. Real life in private practice is different.

It depends on the type of practice.

A well oiled nail farm can see 40 patients a day no problem.

I see about 20-25 a day but I do very little nail care. <10% C&C.

I feel I cant really do a good job and see more than 25 a day. If I just cut nails all day I would probably make more money than I do fixing bunions, etc, etc.

 

[619]

It depends on the type of practice.

A well oiled nail farm can see 40 patients a day no problem.

I see about 20-25 a day but I do very little nail care. <10% C&C.

I feel I cant really do a good job and see more than 25 a day. If I just cut nails all day I would probably make more money than I do fixing bunions, etc, etc.

Well that is true. If you have the MA doing the nails and you're just bouncing from room to room then sure 40 is feasible.

Furthermore, I did not say seeing 40 patients a day is impossible, but is it sustainable year after year? and only making $200K without getting burnt out.

If you own your PP and you are seeing 40 or even 50 a day, you are happy because that is serious bank in your pocket. But being an associate and seeing 40 a day will make you miserable in the long run. Think of your mental well being.

 

[DYK343]

Well that is true. If you have the MA doing the nails and you're just bouncing from room to room then sure 40 is feasible.

Furthermore, I did not say seeing 40 patients a day is impossible, but is it sustainable year after year? and only making $200K without getting burnt out.

If you own your PP and you are seeing 40 or even 50 a day, you are happy because that is serious bank in your pocket. But being an associate and seeing 40 a day will make you miserable in the long run. Think of your mental well being.

I agree totally

 

[G0dFather]

Math as follows (with rounding to simplify)
200k net / 30% = 667k gross
667k gross / $85 per visit (trying to pick a reasonable number) = 7847 patient encounters/year
7847 visits/48 weeks = 164 patients per week
164 patients / 4.5 days worked = 36-37 patients a day

Wow... ok, so much here its crazy. First of all 165 pt per week should def gross you about 900k - 1 mil (even with 50%-60% of those pts being RFC nails & CALLUSES, there should be many new pt visit E&M (especially for you), DME, xrays, injections, many quick profitable minor office procedures etc). 85 bucks average is underbilling/superconservative to your own demise or you work with a very poor insurance mix. Take this calculation for example 165 x 110 x 50 (because you need at the very least you need a 1 week break and 1 week will go to federal holidays) is about 905K

But like mentioned here before the physical and mental toll of averaging 40 pts a day 5 days a week a few years in a row is insane, doing the notes plus coding ( if this portion is taken care of for you it def helps).On top of that doing all that work for a 30 percent deal is rough. If you do get to that level and your now an asset to the office you should negotiate a straight percentage deal with some sort of minimal base to cover your expenses.

 

[heybrother]

Not to sound like a practice management scoundrel - I think there's a point where patient volume increases but you then fail to offer necessary services potentially resulting in less revenue. I don't particularly like it when patients have a million things wrong, but those patients sometimes end up being your matrixectomy + orthotic + ultimately surgery of some sort patient. I've also had quite a few disagreeable people that drive me nuts, but by listening to them we get to something crucial like PVD. I had a lady the other day do the everything hurts, nerve pain, plantar fasciitis pain etc. I talked about claudication, calf/leg/buttock pain, resting pain etc and she's denying everything - I'm a waitress I'm so active...but then I'm lying against a wall crying unable to walk. My ortho thinks its my knee. SFA was occluded.

Random question - a patient presents to your private practice and clearly doesn't have PVD/DM2 (getting a qualifying diagnosis beyond these 2 to stick seems less likely to me...). I personally am very skeptical in 1172X for pain. I had an attending in residency who billed it all the time and there was no way the patients were meeting the listing. Theoretically they could only present for this PRN but they were all being scheduled at 2-3 months and the nurses were getting a pain score prior to the patient being seen which was always zero - I have no pain. If your own documentation says the pain score is zero it seems like you are setting up to lose the audit.

Anyway. Our uncovered nail/callus charge is $70 cash. I have people who literally pay $70 to have one toenail cut. I also have people I work my butt off - 10 calluses who pay $70. The payment is obviously less than Medicare pays for a 11720 + 1105X. More than I would like to - I end up treating plantar fasciitis or whatever and as I try to walk out the door - "doc you forgot my nails". I'm working harder now to have my MA intercept all of that before hand (if they saw another doctor in the practice and it seemed to me the visits were listed as plantar fasciitis or hammertoe, but were really for nails...) and am starting to charge the visit (if its real) + the uncovered service. Not sure how that will fly... haven't done it before.

 

[blasthardcheese]

Wow, this has been an eye-opening thread for me.
1. $85 per visit was meant to be a VERY conservative estimate to show what it would take to hit 200k.

So, the purpose of this thread has changed from trying to help residents see what it's like in PP in the real world to me becoming the example of the person with the job you don't want. It's very humbling. Believe it or not this was one of the better PP offers I had, the other job offers were so bad this one was vastly better. And when you view what others have pointed out above, it doesn't sound like my situation is as great as I thought it was.

Unfortunately, this my reality for the time being. There aren't enough of those high quality hospital/MSG jobs to go around. When you don't want to take on even more debt to open a practice and when you have a family to provide for, you have to take some sort of job.

The unfortunate moral of the story is don't be me.

And, to keep this from being a total doom and gloom post for all the prepods/students/residents reading this, I do enjoy the practice of podiatry very much, it just sounds like someone else is going to reap the fruits of my labor.

Edit: changed eye opening to eye-opening

 

[dtrack22]

it doesn't sound like my situation is as great as I thought it was.

 

[heybrother]

Wow, this has been an eye-opening thread for me.
1. $85 per visit was meant to be a VERY conservative estimate to show what it would take to hit 200k.

So, the purpose of this thread has changed from trying to help residents see what it's like in PP in the real world to me becoming the example of the person with the job you don't want. It's very humbling. Believe it or not this was one of the better PP offers I had, the other job offers were so bad this one was vastly better. And when you view what others have pointed out above, it doesn't sound like my situation is as great as I thought it was.

Unfortunately, this my reality for the time being. There aren't enough of those high quality hospital/MSG jobs to go around. When you don't want to take on even more debt to open a practice and when you have a family to provide for, you have to take some sort of job.

The unfortunate moral of the story is don't be me.

And, to keep this from being a total doom and gloom post for all the prepods/students/residents reading this, I do enjoy the practice of podiatry very much, it just sounds like someone else is going to reap the fruits of my labor.

Edit: changed eye opening to eye-opening

Its an interesting situation to be in. I was thinking recently about one of the other threads where we were looking at PP money. The simple truth through most of time is if you could get - $120K + 30% + health insurance + 401k - you had the best possible deal you could get through PP. So compared to most people through time you are doing very well. For example, I'm substantially worse off than you. Additionally, there was some discussion earlier in the thread about "$25K" in benefits. We can argue about what a benefit is but the vast majority of people are not getting 25K in benefits from a PP associate job. We'd have a lot less to complain about if we did. If my job paid for my family's health insurance I'd have $12K more in my pocket and still wouldn't hit $25K. Obviously, hospital pay should make us view PP pay unkindly.

My big thing - the heart of most of our problems is the 30% collections. Ultimately we all will be paid something resembling what we bring to practices. 30% is NOT what other specialists are making and its borderline impossible to make real money when that's where we top out at.

 

[619]

Its an interesting situation to be in. I was thinking recently about one of the other threads where we were looking at PP money. The simple truth through most of time is if you could get - $120K + 30% + health insurance + 401k - you had the best possible deal you could get through PP. So compared to most people through time you are doing very well. For example, I'm substantially worse off than you. Additionally, there was some discussion earlier in the thread about "$25K" in benefits. We can argue about what a benefit is but the vast majority of people are not getting 25K in benefits from a PP associate job. We'd have a lot less to complain about if we did. If my job paid for my family's health insurance I'd have $12K more in my pocket and still wouldn't hit $25K. Obviously, hospital pay should make us view PP pay unkindly.

My big thing - the heart of most of our problems is the 30% collections. Ultimately we all will be paid something resembling what we bring to practices. 30% is NOT what other specialists are making and its borderline impossible to make real money when that's where we top out at.

The simple truth through most of time is if you could get - $120K + 30% + health insurance + 401k - you had the best possible deal you could get through PP.

I would also agree that $120K base with health insurance paid for and 30% with 401K is the best deal in PP for a new graduate. So no one is bashing @blasthardcheese . You got a good deal.

Thank you for sharing your experience but at the same time, other specialists are doing better than that to their new graduates. Podiatry is a different ball game and the best route is still to join a hospital/MSG group or open up your own PP. You can never be rich or even upper middle class working as an associate for another Podiatrist. Even after working for many years, the buy-in is another different story.

Anybody that has gone from becoming an associate to buying into a practice/becoming partner can explain his or her experience to us. It will be helpful to the rest of us.

 

[Rop]

Just for fun..

What’s stopping a newly graduated pod with a working spouse and no kids from opening up with $50K? Average annual practice rent is on $26K/per year according to APMA. Buy used equipment for 2 rooms, practice fusion is $99/month, do your own billing in the beginning. Even if someone collects only $250K first year out cold seeing 10 +/- patients a day for 50 weeks ($100 +/- /pt avg) then thats about as good as you would’ve gotten from an associate contract (assuming 50% overhead) except you’re the practice owner and can expect even more the following years. Why does it require $200K to open up?

Could a young pod open up a 2 room practice with $50K, use a family member as the interim office manager, run everything in the backend yourself, and expand from there?

I know it takes 6 months-1 year to get on panels which slows down cash flow...initially.

 

[619]

Just for fun..

What’s stopping a newly graduated pod with a working spouse and no kids from opening up with $50K? Average annual practice rent is on $26K/per year according to APMA. Buy used equipment for 2 rooms, practice fusion is $99/month, do your own billing in the beginning. Even if someone collects only $250K first year out cold seeing 10 +/- patients a day for 50 weeks ($100 +/- /pt avg) then thats about as good as you would’ve gotten from an associate contract (assuming 50% overhead) except you’re the practice owner and can expect even more the following years. Why does it require $200K to open up?

Could a young pod open up a 2 room practice with $50K, use a family member as the interim office manager, run everything in the backend yourself, and expand from there?

I know it takes 6 months-1 year to get on panels which slows down cash flow...initially.

This is great and it is feasibly. How many podiatry associate work in an outpost clinic 1-2 days a week. The clinic is literally tables and chair. No x Ray or anything fancy. But somehow you see and treat patients. All you need is your BRAIN.

If you need x Ray or anything, you write a script and see them in a week for follow up. 99% of the time, you already know the diagnosis from H&p and an X Ray is not going to change your plan of care. Except acute trauma, you may need x ray to treat the patient. Even with acute trauma without x-ray, you still offload with a CAM boots or a cast with crutches, with or without an x Ray, if patient can't put weight on the foot. You treat patient not the X-Ray

So I think you are right. You don't need $200k to open a practice. Can be done with $50K. But then in reality, most people have bills and dependents.

 

[deleted1061086]

Any idea what percentage of production other specialties are taking home? Are they taking home 40, 50, or 60% of collections? And if that is the case, why are we in a situation where even 35% (usually after collecting 3 times your salary) would be considered a win.

I know this has been beaten to death. But imagine a successful and busy first year associate. Imagine they collect 600k. Their contract is 100k with 30% collections after 300k.

associate takes home 200k
private practice owner has 400k left over to play with. Let’s say your overhead is 100k. Private practice owner takes home 300k - profit.

so you did all the work, took the liability if you are surgical, yet even after overhead is paid, the private practice owner is taking home significantly more of what you produced than you are.

So how did it end up like this?

 

[619]

Any idea what percentage of production other specialties are taking home? Are they taking home 40, 50, or 60% of collections? And if that is the case, why are we in a situation where even 35% (usually after collecting 3 times your salary) would be considered a win.

I know this has been beaten to death. But imagine a successful and busy first year associate. Imagine they collect 600k. Their contract is 100k with 30% collections after 300k.

associate takes home 200k
private practice owner has 400k left over to play with. Let’s say your overhead is 100k. Private practice owner takes home 300k - profit.

so you did all the work, took the liability if you are surgical, yet even after overhead is paid, the private practice owner is taking home significantly more of what you produced than you are.

So how did it end up like this?

People will say it's the "old eating their young". I will say the "young are now eating their fellow young" . A lot of younger podiatrist buying up an overpriced expensive practice from a retiring old pod would want to recoup their money fast to pay back the bank loan. So you can't blame them either.

It's a cycle that I do not see an end in sight. Except getting a hospital job or opening up your own PP. Working as an associate for another Podiatrist won't make you a good living.

 

[heybrother]

I think people do really need to ask themselves what they need - but x-ray isn't the thing I'd skip. I always laugh reading associate job postings where the clinic boasts of all the unnecessary crap they have. Lasers and this and that. Things that in truth shouldn't be used a single time in a month. And of course they'll be pushed on all.

An x-ray is helpful all around. Patients appreciate it. In fact, they often expect it. Most people think they have a fracture for anything that hurts. There's likely a liability component - someone out there would say - "and the podiatrist never x-rayed you!?!" It allows you to follow more pathology ie. healing fractures. It allows you to discuss/book surgeries and follow them. It catches weird things you would not see coming. I had a patient with heel pain once who never related prior surgery - the weird lump was actually a screw. Another patient I thought had weird 1st MPJ arthritis actually had a implant they didn't know about. Absurd - would have found out eventually, but nice to know on the spot. From a practice management perspective - I think it probably pays for itself very quickly. Plans are variable but x-rays seems to pay about $25-32 a foot in my area.

Now let me throw something at you - I started out telling myself I was just going to use my brain. My residency director was all about the exam, the history, understanding it all. You don't need an x-ray (or hell, an MRI) for plantar plate issues. Look at the damn toe. Feel where the pain is. Feel the MPJ. You don't need an x-ray for plantar fasciitis cause we don't care about the spur and a stress fracture is almost always clinically obvious.. So I tried during about my 1st month to not x-ray and it just really was a nuisance. Encounters are about efficiency, confidence, being definitive, avoiding awkward moments. Why haven't you x-rayed me yet!? Now I get the x-ray, have a definitive encounter, and hopefully move on. Hit them with a minimalist, easy effective therapy, shoes, stretching, insert, med and see the next patient. Goal is encounter number 2 is I feel great, cya.

Small aside - the vast, vast majority of people who present to my office - no matter what they say about their ankle hurting - have foot pathology. Achilles, PTTD. Sinus tarsi. etc. In my residency clinic we had an x-ray tech who had autonomy to do x-rays she thought were necessary (right or wrong). Honestly, we worked with her constantly and she did a great job. She had another person who covered for her occasionally and if they were there every single patient somehow had ankle, foot, etc of every view. If there's a question about getting an ankle x-ray my MA just comes and gets me to examine first.

 

[619]

I think people do really need to ask themselves what they need - but x-ray isn't the thing I'd skip. I always laugh reading associate job postings where the clinic boasts of all the unnecessary crap they have. Lasers and this and that. Things that in truth shouldn't be used a single time in a month. And of course they'll be pushed on all.

An x-ray is helpful all around. Patients appreciate it. In fact, they often expect it. Most people think they have a fracture for anything that hurts. There's likely a liability component - someone out there would say - "and the podiatrist never x-rayed you!?!" It allows you to follow more pathology ie. healing fractures. It allows you to discuss/book surgeries and follow them. It catches weird things you would not see coming. I had a patient with heel pain once who never related prior surgery - the weird lump was actually a screw. Another patient I thought had weird 1st MPJ arthritis actually had a implant they didn't know about. Absurd - would have found out eventually, but nice to know on the spot. From a practice management perspective - I think it probably pays for itself very quickly. Plans are variable but x-rays seems to pay about $25-32 a foot in my area.

Now let me throw something at you - I started out telling myself I was just going to use my brain. My residency director was all about the exam, the history, understanding it all. You don't need an x-ray (or hell, an MRI) for plantar plate issues. Look at the damn toe. Feel where the pain is. Feel the MPJ. You don't need an x-ray for plantar fasciitis cause we don't care about the spur and a stress fracture is almost always clinically obvious.. So I tried during about my 1st month to not x-ray and it just really was a nuisance. Encounters are about efficiency, confidence, being definitive, avoiding awkward moments. Why haven't you x-rayed me yet!? Now I get the x-ray, have a definitive encounter, and hopefully move on. Hit them with a minimalist, easy effective therapy, shoes, stretching, insert, med and see the next patient. Goal is encounter number 2 is I feel great, cya.

Small aside - the vast, vast majority of people who present to my office - no matter what they say about their ankle hurting - have foot pathology. Achilles, PTTD. Sinus tarsi. etc. In my residency clinic we had an x-ray tech who had autonomy to do x-rays she thought were necessary (right or wrong). Honestly, we worked with her constantly and she did a great job. She had another person who covered for her occasionally and if they were there every single patient somehow had ankle, foot, etc of every view. If there's a question about getting an ankle x-ray my MA just comes and gets me to examine first.

I agree with you that x ray is necessary and some patient often expect it. However, this is for a situation for a young pod starting out on his or her own on a tight budget. You can always buy an X Ray after patient is volume is up and income is coming in

Also a lot of pod offices with 5-6 office locations, with 2-3 in a small town in the middle of no where seeing patients once a week where they do not have x ray. If you want to confirm diagnosis, you can always write a script for patient to get x ray at the imaging center/hospital and come back in a few days. In these days of tele-health, you can even call them over the phone/video call with the EHR and tell them the result and also show them the images.

What I am saying it, at the least all you need is tables, chairs, few office supplies and most important a BRAIN to run a podiatry clinic. X-Ray can come in later after few months in practice and getting on all the insurance panels. The same way you don't need more than 3-4 rooms starting out. After a couple years of being busy, you can mortgage an office building or rent out a bigger space.

This is about starting out small on a tight budget. Not having an X Ray in office is you taking a risk but life is about risk.

 

[air bud]

I think people do really need to ask themselves what they need - but x-ray isn't the thing I'd skip. I always laugh reading associate job postings where the clinic boasts of all the unnecessary crap they have. Lasers and this and that. Things that in truth shouldn't be used a single time in a month. And of course they'll be pushed on all.

An x-ray is helpful all around. Patients appreciate it. In fact, they often expect it. Most people think they have a fracture for anything that hurts. There's likely a liability component - someone out there would say - "and the podiatrist never x-rayed you!?!" It allows you to follow more pathology ie. healing fractures. It allows you to discuss/book surgeries and follow them. It catches weird things you would not see coming. I had a patient with heel pain once who never related prior surgery - the weird lump was actually a screw. Another patient I thought had weird 1st MPJ arthritis actually had a implant they didn't know about. Absurd - would have found out eventually, but nice to know on the spot. From a practice management perspective - I think it probably pays for itself very quickly. Plans are variable but x-rays seems to pay about $25-32 a foot in my area.

Now let me throw something at you - I started out telling myself I was just going to use my brain. My residency director was all about the exam, the history, understanding it all. You don't need an x-ray (or hell, an MRI) for plantar plate issues. Look at the damn toe. Feel where the pain is. Feel the MPJ. You don't need an x-ray for plantar fasciitis cause we don't care about the spur and a stress fracture is almost always clinically obvious.. So I tried during about my 1st month to not x-ray and it just really was a nuisance. Encounters are about efficiency, confidence, being definitive, avoiding awkward moments. Why haven't you x-rayed me yet!? Now I get the x-ray, have a definitive encounter, and hopefully move on. Hit them with a minimalist, easy effective therapy, shoes, stretching, insert, med and see the next patient. Goal is encounter number 2 is I feel great, cya.

Small aside - the vast, vast majority of people who present to my office - no matter what they say about their ankle hurting - have foot pathology. Achilles, PTTD. Sinus tarsi. etc. In my residency clinic we had an x-ray tech who had autonomy to do x-rays she thought were necessary (right or wrong). Honestly, we worked with her constantly and she did a great job. She had another person who covered for her occasionally and if they were there every single patient somehow had ankle, foot, etc of every view. If there's a question about getting an ankle x-ray my MA just comes and gets me to examine first.

Facts - I hate getting x-rays and only do when truly needed in my current Hospital job. It takes for ever, costs the patient more and doesn't result in money in my pocket. As I leave and transition to private practice, you better believe I am xraying the crap out of stuff. I also expect it to be much more efficient.

 

[blasthardcheese]

@NewPodGrad2019 thanks. Just didn't really want this thread to be a hospital job vs PP as that horse has been beaten to death on these forums. However, I am finding the direction this thread is currently going interesting and am learning a lot.

 

[619]

Facts - I hate getting x-rays and only do when truly needed in my current Hospital job. It takes for ever, costs the patient more and doesn't result in money in my pocket. As I leave and transition to private practice, you better believe I am xraying the crap out of stuff. I also expect it to be much more efficient.

Furthermore, a lot of hospital employed folks don't have an x-ray in their clinic readily available. They often have to send the patient to get x ray at the hospital/hospital imaging center. So it's basically the same as a PP owner with no x ray in-house sending the patients to the same hospital/imaging center to get x-ray.

I also believe having x ray in clinic and patients expecting it is an "American healthcare luxury". Other parts of the western world don't have x ray readily available like that in their clinic the way we do here. It does not make their healthcare any less inferior to ours because we x ray everything that walks through the door.

We must admit we take x rays in office even when it's not needed because the x ray is in-house and readily available. Lastly, it makes the patient happy and we get paid for it.

 

[G0dFather]

Wow, this has been an eye-opening thread for me.
1. $85 per visit was meant to be a VERY conservative estimate to show what it would take to hit 200k.

So, the purpose of this thread has changed from trying to help residents see what it's like in PP in the real world to me becoming the example of the person with the job you don't want. It's very humbling. Believe it or not this was one of the better PP offers I had, the other job offers were so bad this one was vastly better. And when you view what others have pointed out above, it doesn't sound like my situation is as great as I thought it was.

Unfortunately, this my reality for the time being. There aren't enough of those high quality hospital/MSG jobs to go around. When you don't want to take on even more debt to open a practice and when you have a family to provide for, you have to take some sort of job.

The unfortunate moral of the story is don't be me.

And, to keep this from being a total doom and gloom post for all the prepods/students/residents reading this, I do enjoy the practice of podiatry very much, it just sounds like someone else is going to reap the fruits of my labor.

Edit: changed eye opening to eye-opening

Hey no need to feel that way... for a first contract and given your situation you picked up something great that is available in the pod market .... not all hospital jobs/msg/ortho are as high quality as portrayed here, at the end of the day what's mentioned here is a handful of he said she said and the need to cold call/sell yourself ( not what you want to risk all that time and money on) ..... you will always have a situation where a percentage of what you make is taken regardless of PP, hospital/pod/msg/ortho jobs , the best ive seen offered is 40-50% of what you earn as a pod associate.... many offices have an overhead of 40-60 percent, so an associate that is taking home 40-50% of what is earned paid out to a corp that he/she can then manage the money in is better off without the headache of running an office, etc.

Just for fun..

What’s stopping a newly graduated pod with a working spouse and no kids from opening up with $50K? Average annual practice rent is on $26K/per year according to APMA. Buy used equipment for 2 rooms, practice fusion is $99/month, do your own billing in the beginning. Even if someone collects only $250K first year out cold seeing 10 +/- patients a day for 50 weeks ($100 +/- /pt avg) then thats about as good as you would’ve gotten from an associate contract (assuming 50% overhead) except you’re the practice owner and can expect even more the following years. Why does it require $200K to open up?

Could a young pod open up a 2 room practice with $50K, use a family member as the interim office manager, run everything in the backend yourself, and expand from there?

I know it takes 6 months-1 year to get on panels which slows down cash flow...initially.

Yes 50K is possible and i think i have mentioned this before , one will need more tho to pay himself until the business can do that for you ... it also depends of ones situation and the location...but starting cold is very tough, one should focus more on high revenue but with the right marketing and hustle in about a year one can get busy 50 pts billed correctly a week will generate about 250K, possible more as you will have more time to be thorough with your patients

so you did all the work, took the liability if you are surgical, yet even after overhead is paid, the private practice owner is taking home significantly more of what you produced than you are.

this is the sad situation but not everyone is like this ... also if you prove that your on point in an office in a way the owner is beholden to you .... its a lot of headache to move pts around when an associate leaves and acclimate pts to a new one, insurance paperwork etc.. many patients can be lost in the transition... noone wants to have to deal with this on a regular basis

 

[heybrother]

I've been places where the joke is you can't see an orthopedist without an MRI from their imaging center in your hand. It is worth considering the impact and expense our services inflict on patients. I was added to a new panel (a rare, weird, ridiculous panel that pays unbelievably for surgery) the other day and read the contract. I'm guessing no one at our clinic had read it before because it turns out this insurance will pay more per E&M visits than my clinic is currently charging. I looked through it, thought about the additional payment and just filed it away. I think our charges are in line with the service we render. How much damn money should it really cost for a patient to be seen for a basic MSK problem. We're optimized for Cigna and BCBS already.

Our podiatry "forefathers" had to develop their x-rays in their own clinic and had to wait for intra-op x-rays or potentially take patients back to the OR. We live in luxurious time. We can fret about it or we can enjoy it. I don't disagree with anything you're saying. I just enjoy the convenience of it all. I didn't have a smart phone till I went to podiatry school. The world just keeps getting better for me.

 

[air bud]

Furthermore, a lot of hospital employed folks don't have an x-ray in their clinic readily available. They often have to send the patient to get x ray at the hospital/hospital imaging center. So it's basically the same as a PP owner with no x ray in-house sending the patients to the same hospital/imaging center to get x-ray.

I also believe having x ray in clinic and patients expecting it is an "American healthcare luxury". Other parts of the western world don't have x ray readily available like that in their clinic the way we do here. It does not make their healthcare any less inferior to ours because we x ray everything that walks through the door.

We must admit we take x rays in office even when it's not needed because the x ray is in-house and readily available. Lastly, it makes the patient happy and we get paid for it.

This

 

[heybrother]

Next you'll say that in office vascular testing, $60K wart sticker, pain laser, in office PCR lab, shockwave, and nitrous are luxuries wink!

 

[air bud]

Next you'll say that in office vascular testing, $60K wart sticker, pain laser, in office PCR lab, shockwave, and nitrous are luxuries wink!

Don't forget in office amniotic tissue incubator. It's the new hot thing. Surprised haven't seen it in PM news yet

 

[SouthPod7]

I end up treating plantar fasciitis or whatever and as I try to walk out the door - "doc you forgot my nails".

I felt this in my soul.

 

[Pronation]

Just a friendly end of the year reminder to all looking at joining a podiatry group...

You are joining an associate mill if:

1) The practice is 10+ years old and the most senior associate has only been there for 2 or 3 years.

2) There are no partners, everybody is an associate. Rest assured that the owner will tell you that the most senior associate is in the process of becoming a partner (hint: it'll never happen).

Protip: You will get used and abused at one of these associate mills. No matter how many lies the practice owner tells you, start working on an escape plan from the day you join...

 

[heybrother]

Just a friendly end of the year reminder to all looking at joining a podiatry group...

You are joining an associate mill if:

1) The practice is 10+ years old and the most senior associate has only been there for 2 or 3 years.

2) There are no partners, everybody is an associate. Rest assured that the owner will tell you that the most senior associate is in the process of becoming a partner (hint: it'll never happen).

Protip: You will get used and abused at one of these associate mills. No matter how many lies the practice owner tells you, start working on an escape plan from the day you join...

A guy once told me his associate left because her husband was angry there wasn't a Lexus dealership in town to service his car. They were like 30 minutes from a rich Dallas suburb. God I ...love this profession.