Percentage of new grads joining small democratic groups?

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theblueswede

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I read all the time about the decline of small democratic groups in emergency medicine. I hope one day to join one as a partner, however, so I'm wondering how easily this is accomplished for the average EM grad in 2018. Approximately what percentage of new EM attendings are going this route each year?

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I am finding many SDGs (in my area) don’t want new grads. But who can blame them. Why hire a new grad who sucks like an intern, if they can hire someone else with experience.
 
I am finding many SDGs (in my area) don’t want new grads. But who can blame them. Why hire a new grad who sucks like an intern, if they can hire someone else with experience.

Makes sense. I hope to practice in a pretty desirable area, so one thought has been to spend something like 5 years in an employed position somewhere else while patiently applying to SDNs in my area of choice till I get a bite. Based on what you're saying, perhaps this is more feasible in general anyway than getting into an SDN right out of residency.
 
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Makes sense. I hope to practice in a pretty desirable area, so one thought has been to spend something like 5 years in an employed position somewhere else while patiently applying to SDNs in my area of choice till I get a bite. Based on what you're saying, perhaps this is more feasible in general anyway than getting into an SDN right out of residency.

*SDG lol
 
I'm sure they are out there. I've never worked for one but I'm always on the lookout for a well run SDG. That being said...I've almost worked for 2 during my career and both got bought out by a CMG within a few years. I'm really glad I didn't go with the last one because it would have been 50% sweat equity buy in and they would have been bought out almost exactly 1 month before I would have been due to make partner. I got lucky on that one!
 
Also, any thoughts about what portion of EM physicians overall are in SDGs?
 
Last stat I heard was 8% are in SDGs, but I'll bet the % of new docs going into them is lower than that given trends.

8%. Wow. That is lower than I'd feared…not very encouraging. I appreciate the reply, however—I have struggled to find a clear answer to that question.

Hopefully these current trends will stabilize sometime soon...
 
I read all the time about the decline of small democratic groups in emergency medicine. I hope one day to join one as a partner, however, so I'm wondering how easily this is accomplished for the average EM grad in 2018. Approximately what percentage of new EM attendings are going this route each year?

Only 1 of 12 residents in my class joined an SDG.

At least for my class, the main issue was that everyone (except me and the SDG guy) "needed" to live in a certain location after finishing and there were hardly any SDGs in those places. I interviewed with 1 SDG but there was a 2y partnership track that could've cost me ~$400K so I just sold my soul to TH instead.

This might suggest a strategy for you if you care a whole lot about this: look for SDGs in out-of-the-way places that are unattractive to new grads (eg, not on a coast) but have potentially good payor mixes. Maybe start with non-Medicaid-expansion states? I think someone posted a list a while back.
 
Sad to hear SDGs are doing this. I found 2 SDGs in 2 great cities. Buyin for the first was steep but worked out as it was likely a top 5 job in the US. Insane payer mix, full consultant board etc.

SDG #2 low buy in, during buyin I made more than any CMG job around.

I too got lucky as I seriously considered another SDG but got a bad vibe. Fast Forward 9 months later they lost their contract due to USACS shadiness and another SDG screwing them over.

Ill simply say you would have to be very careful with a hefty buyin. Keep in mind your real buyin isnt the delta between you and the partners but rather what you will make and what the CMGs or hospitals pay in your neighborhood.
 
Sad to hear SDGs are doing this. I found 2 SDGs in 2 great cities. Buyin for the first was steep but worked out as it was likely a top 5 job in the US. Insane payer mix, full consultant board etc.

SDG #2 low buy in, during buyin I made more than any CMG job around.

I too got lucky as I seriously considered another SDG but got a bad vibe. Fast Forward 9 months later they lost their contract due to USACS shadiness and another SDG screwing them over.

Ill simply say you would have to be very careful with a hefty buyin. Keep in mind your real buyin isnt the delta between you and the partners but rather what you will make and what the CMGs or hospitals pay in your neighborhood.
My residents last year

1 Academic fellowship
2 CMGs
1 Hospital employed
3 SDG
1 large DG

So 3/8 went to SDGs in SoCar, Texas and Ohio. ONe of the others had 2 job offers at an SDG but decided to take a hospital employed position due to location.
 
Sad to hear SDGs are doing this. I found 2 SDGs in 2 great cities. Buyin for the first was steep but worked out as it was likely a top 5 job in the US. Insane payer mix, full consultant board etc.
So, therein lie the questions: first, if it was a top 5 job in the entire country, why did they take you, fresh out of residency? And, second, why did you leave it?

Not hammering on you, but, it always sounds like you have a lucky horseshoe up your butt.
 
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We have hired way more new grads over the past 5 years than experienced physicians. We have found experienced hires usually require some sort of "deal" or deviation from standard partnership track. Between 20-40% of our local residency class each year goes to an SDG. I am fortunate to live in a medium/large city that is run by SDGs except for academic jobs. Our track is arduous and it does cost some money upfront but the pay off so far has been astronomical. I can't agree with EctopicFetus more. Having control of your job, who you hire, where you work, schedule, pay, employee pay, benefits, etc. helps combat burnout. No job is perfect. We have had a lot of growing pains the past three years and stress with hiring, but it has worked out well so far. After this job, I couldn't see myself working for a CMG. I am hoping when the party is over I will be FI and won't have to work more than 1/2 time. Only time will tell.
 
We have hired way more new grads over the past 5 years than experienced physicians. We have found experienced hires usually require some sort of "deal" or deviation from standard partnership track. Between 20-40% of our local residency class each year goes to an SDG. I can't agree with EctopicFetus more. Having control of your job, who you hire, where you work, schedule, pay, employee pay, benefits, etc. helps combat burnout. No job is perfect. After this job, I couldn't see myself working for a CMG. I am hoping when the party is over I will be FI and won't have to work more than 1/2 time. Only time will tell.

+1. Our last 6 hires in my SDG were new residency grads.


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So, therein lie the questions: first, if it was a top 5 job in the entire country, why did they take you, fresh out of residency? And, second, why did you leave it?

Not hammering on you, but, it always sounds like you have a lucky horseshoe up your butt.
Strong ties to my residency. Like half the docs in the group did residency at the same place. 90% of hires were new. From being in charge of hiring there to being involved here experience works 2 ways. Some people come out crispy from their trash CMG jobs and bring that trash attitude to their SDGs. Ask WCI, he knows about the old job.

I left because the geezer docs decided that emcare money was more important than principle and protecting the younger docs. Top 5 job became CMG trash. Want proof? During my 6 years there we had 5 docs leave. 3 retired and 1 went on to start-up a telemedicine job, 1 left due to a sick child.

In the 2 years after the sale 20/40 docs left and numerous hires came and went. No one ever left that job previously.

At my new SDG the only way to get a job is to be a known entity. We just hired 2 new grads. probably 75% of our hires are new grads. Ill say I am always a little skeptical of "experienced" docs as they are often difficult to redirect (I realize this became me).

I have a horseshoe but based on what I know it isnt up my butt. That would be terrible luck if it was there. My 2 jobs post residency have both been significantly above market.
 
It's going to be hard for SDG's to survive in the coming years. Much like hospitals that have had to merge to stay afloat with the ever smaller payments and increasing regulatory requirements, you'll soon find that the power of a CMG will pretty much make all SDG's disappear. Having large numbers of billing specialists, counsel, etc. is to the advantage of a CMG. Unfortunately, the power of the CMG can also drive down provider salaries.
 
It's going to be hard for SDG's to survive in the coming years. Much like hospitals that have had to merge to stay afloat with the ever smaller payments and increasing regulatory requirements, you'll soon find that the power of a CMG will pretty much make all SDG's disappear. Having large numbers of billing specialists, counsel, etc. is to the advantage of a CMG. Unfortunately, the power of the CMG can also drive down provider salaries.
This is total BS dude. The CMGs have scale and the SDGs have commitment and being nimble on their side.

Part by part
1) Billing specialists - outsource it. The billing companies are better than the CMGs at billing.
2) Counsel - I assume you mean attorneys? These are a dime a dozen and the good ones work for themselves and not as in house counsel.

I mean the advantage of CMGs is their recruiting infrastructure to cover crap hospitals. Their docs are generally not loyal to them. They dont do extra (and why should they). I think the CMG BS is being pushed through via ACEP.

While I would agree that insurance reimbursement for CMGs is on average higher so is their overhead and what you see United doing is squeezing them back. Its smart. Many hospitals require their ED groups to be contracted with the major insurers (BCBS/Anthem/United/Cigna/Aetna etc.). Some hospitals dont care as much. What United is doing is trying to cut their pay to EmCare by utilizing this fact. You dont suppose the other insurers will do the same?
 
The SDG I signed with has a quarter million buy in

pray for me
 
The SDG I signed with has a quarter million buy in

pray for me
Why would any respectable SDG who wants good docs to stay on require a 1/4 mil buy in? Seriously.

If they really want you, they would just pay you less than the partner over 2 yrs and call it your buy in.

But what you signed up for is taking all of the risk.
 
Why would any respectable SDG who wants good docs to stay on require a 1/4 mil buy in? Seriously.

If they really want you, they would just pay you less than the partner over 2 yrs and call it your buy in.

But what you signed up for is taking all of the risk.
I assume that’s what he means as a buy in. Not writing a check for 250k.


I view the buy in as how much less I make than a partner.

250k isn’t bad.

Depends on the job. Our non partners will make more than any cmg job in town. Makes it a no brainer when they look at their options.
 
I assume that’s what he means as a buy in. Not writing a check for 250k.


I view the buy in as how much less I make than a partner.

250k isn’t bad.

Depends on the job. Our non partners will make more than any cmg job in town. Makes it a no brainer when they look at their options.

Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛
 
Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛

Wait wait wait. Why are you doing this? Are you taking out personal loan to foot this? And you make $150 / hr as pre-partner? What do the partners make? How long is pre-partner track? Honestly, this sounds terrible. I'd rather work for USUCK. Why not do locums?
 
Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛

Bummer since they’re clearly doing sweat equity in addition to equity equity.

Hopefully your wife is an orthoplaticsdermneurosurgeon and it will all even out.

That said, I worked heavily at a place 1.5hrs away for two years and it was hell for my wife. If all your family is in that area too, I can get your intentions but you need to at least consider locums. Eyes wide open. Good luck.


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Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛
When I was interviewing for jobs a few years ago, 150/hr was fairly average for SDG sweat equity buy ins. I don't think that number actually sounds that bad. Would imagine that in Midwest, you will be making some decent money after the associate years. 250k investment is probably reasonable when you get a mil back after being bought out by the next cmg. Some times I think about going back and looking for that deal somewhere considering my group got bought out after my first 2 years. Now I work for Walmart and I didn't make partner before that happened. Ended up with a smaller fraction of what the partners got. EM man...

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Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛

Good Luck and I hope you make partner. Life throws us too many fastballs for me to justify 250K buy in. That is a big anchor that will weigh on you forever that will make it very hard for you to leave. What happens if your wife can't find a decent gig in town or you have to move for family reasons?

I have never heard of such a predatory SDG set up. It seems to create a dysfunctional group. If I were a partner, I would hope that my partners retire/leave the group so I can grab another share of that buying and lower rate. Doesn't seem like a great set up.

Y0u also better hope the SDG doesn't see a big drop in reimbursement or get taken over by a CMG. You can kiss that 250K and any increase in income goodbye.

Also, unless you are rich, I suspect most are taking out a 250K loan to join the group? How is anyone going to get a 250K unsecured loan without some insane term? The more I think about it, the more I think SDG is predatory.
 
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Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛

I’m a new grad in a SDG as well. Your rate is horrible. I made that as a resident moonlighting. No way I would work there for 150/hr and then give them a check for 250k just seems like robbery....
 
This shows my ineptitude regarding the business side of medicine, but could a stipulation be added to a contract with an SDG that if they get bought out by a CMG during your buy-in phase, you get paid out as a partner?
 
This shows my ineptitude regarding the business side of medicine, but could a stipulation be added to a contract with an SDG that if they get bought out by a CMG during your buy-in phase, you get paid out as a partner?
Sure. If it’s a great job with 19 applicants for 1 spot why would they?
 
Oh no, I was quite literal. I'm going to a midwest town where salaries in general are low across the board for personal/family reasons. I'd have to drive 1.5 hrs a day for any better pay (one way). No thanks. I'd rather be with my wife, who is faculty on a track at a local institution.

It's a 250k check written for the buy in. We also make only $150 to start out with before being partner.

I'm probably screwing myself but since we're gonna stay long-term in this area due to her job I just accept I'll be one of the lowest, if not the lowest, paid grad in my residency. You can't make 99th percentile without me supporting you from the bottom 😛

The more I think about this, the more crazy your job is. Like slave labor crazy and not one of the highest paid medical field.

Lets assume you work average 140hrs/mo x 150/hr = 21K and after taxes would be about 15K or 17 months to get to 250K.

That is Almost 17 months of FREE labor with the added bonus of uncertainty of being taken over/bought out/not making partner/fired.

How would you like it if you wrote them a 250K check and a wk later you find out that Emcare is buying the group out? You would be left with nothing and the partners are splitting your 250K on top of the buy in.

I would find another gig no matter how much you love this area.

Think about it from another angle. If someone offered you a job where there is no buy in and you are a partner in 17 months, but you have to work a full time job for 17 months for NO PAY. Would you take it?

Well the deal you signed at 250K buyin and 150/hr is actually a worse deal -- Alot worse.
 
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The more I think about this, the more crazy your job is. Like slave labor crazy and not one of the highest paid medical field.

Lets assume you work average 140hrs/mo x 150/hr = 21K and after taxes would be about 15K or 17 months to get to 250K.

That is Almost 17 months of FREE labor with the added bonus of uncertainty of being taken over/bought out/not making partner/fired.

How would you like it if you wrote them a 250K check and a wk later you find out that Emcare is buying the group out? You would be left with nothing and the partners are splitting your 250K on top of the buy in.

I would find another gig no matter how much you love this area.

Think about it from another angle. If someone offered you a job where there is no buy in and you are a partner in 17 months, but you have to work a full time job for 17 months for NO PAY. Would you take it?

Well the deal you signed at 250K buyin and 150/hr is actually a worse deal -- Alot worse.

Oh, I'm cognizant.

The alternative is get divorced from wife on career track at university where they do her specific kind of research and no where else

or drive hours every day one way for a job higher paying. My satisfaction would be so, so much lower with an extra 3 hr drive for a job that pays (and I know this for fact and was offered) 240/hr in a more rural area.

So it's not really about loving the area, it's loving the wife.The local CMG (TH) I can also join is 180/hr and honestly looked kinda...meh. If I stay with this group for a decade or more and it miraculously doesn't get bought out and no partnership snafus it will work out in long run....or so I tell myself.

Sorry, didn't meant to threadjack this topic and make it all about me. Again I am, I suppose, in the minority.
 
Oh, I'm cognizant.

The alternative is get divorced from wife on career track at university where they do her specific kind of research and no where else

or drive hours every day one way for a job higher paying. My satisfaction would be so, so much lower with an extra 3 hr drive for a job that pays (and I know this for fact and was offered) 240/hr in a more rural area.

So it's not really about loving the area, it's loving the wife.The local CMG (TH) I can also join is 180/hr and honestly looked kinda...meh. If I stay with this group for a decade or more and it miraculously doesn't get bought out and no partnership snafus it will work out in long run....or so I tell myself.

Sorry, didn't meant to threadjack this topic and make it all about me. Again I am, I suppose, in the minority.

It's a good sidetrack (much better than the usual SDN highjackings) because I think it displays the important point that predatory "SDGs" are just as nefarious as CMGs. Honestly, it's none of our business to judge your marriage but personally, I would take a hard look at my own if my spouse were handcuffing us into committing a huge financial blunder.
 
Oh, I'm cognizant.

The alternative is get divorced from wife on career track at university where they do her specific kind of research and no where else

or drive hours every day one way for a job higher paying. My satisfaction would be so, so much lower with an extra 3 hr drive for a job that pays (and I know this for fact and was offered) 240/hr in a more rural area.

So it's not really about loving the area, it's loving the wife.The local CMG (TH) I can also join is 180/hr and honestly looked kinda...meh. If I stay with this group for a decade or more and it miraculously doesn't get bought out and no partnership snafus it will work out in long run....or so I tell myself.

Sorry, didn't meant to threadjack this topic and make it all about me. Again I am, I suppose, in the minority.

Get a hotel and see if you can bundle your shifts or so locums and fly and bundle your shifts. One shop I have is about an hour drive and The CMG pays for my gas and my hotel
 
Oh, I'm cognizant.

The alternative is get divorced from wife on career track at university where they do her specific kind of research and no where else

or drive hours every day one way for a job higher paying. My satisfaction would be so, so much lower with an extra 3 hr drive for a job that pays (and I know this for fact and was offered) 240/hr in a more rural area.

So it's not really about loving the area, it's loving the wife.The local CMG (TH) I can also join is 180/hr and honestly looked kinda...meh. If I stay with this group for a decade or more and it miraculously doesn't get bought out and no partnership snafus it will work out in long run....or so I tell myself.

Sorry, didn't meant to threadjack this topic and make it all about me. Again I am, I suppose, in the minority.

You are an MD and have to be reasonable smart. I also understand that everyone has their own situation that no one can judge.

But this SDG setup is worse than any CMG or SDG I have ever seen. I was in a SDG that was completely democratic and let me just share our setup.

1. Everyone shared the same nights, weekends holidays
2. Partners made about 40K extra in profit sharing at the end of the year
3. Everyone got about a 10K bonus at the end of the year
4. Everyone had the same Pay scale and structure
5. This is one of the hardest market to get a job and have a long list of docs waiting to enter
6. When I was hired on, they hired just ONE doctor for the whole year. No one ever leaves.
7. Buy in after 2 years was 100K. Thus you made your money back in alittle more than 2 yrs.

I can tell you that our partners would NEVER vote to change this structure to suck more $$$ out of new partners or have a set up where we could easily "screw" our pre-partners.

The way the partners has set this buy in up, it tells me alot about their character with the way they treat pre-partners.

I could not sleep well at night if we were taken over and these doctors have a 200K+ in debt that the partners are sharing.
 
In a perfect world, we'd all join SDGs and get paid bank. However, they're drying up left and right. Texas (my home) is almost all CMGs in the urban areas which makes my heart hurt.

And sorry, but I'm not giving up $200,000 in income over the first two years to buy into a group. Not when most of us have $200-300k in loans looming over our heads, with no guarantee that the SDG won't lose their contract in the next couple of years.
 
Get a hotel and see if you can bundle your shifts or so locums and fly and bundle your shifts. One shop I have is about an hour drive and The CMG pays for my gas and my hotel

Agreed.

Having to drive 3 hours every day sucks and is bad for your marriage.

But if you can block off shifts and drive 3 hours once a week its very doable and leaves you more free time to spend with family.
 
Agreed.

Having to drive 3 hours every day sucks and is bad for your marriage.

But if you can block off shifts and drive 3 hours once a week its very doable and leaves you more free time to spend with family.

I dunno, I kinda disagree

Getting a hotel and staying there for a week is convenient, but then I'm like doing residency all over again. The point of graduating is that we can finally live together (vs now, where my residency is a few hours from her uni)!

I chose the lower pay. The other thing to keep in mind is she's not a stay-at-home house wife barefoot and pregnant, she herself has a six figure job. It somewhat offsets things (and unlike myself, she has zero debt and owns a condo)
 
I dunno, I kinda disagree

Getting a hotel and staying there for a week is convenient, but then I'm like doing residency all over again. The point of graduating is that we can finally live together (vs now, where my residency is a few hours from her uni)!

I chose the lower pay. The other thing to keep in mind is she's not a stay-at-home house wife barefoot and pregnant, she herself has a six figure job. It somewhat offsets things (and unlike myself, she has zero debt and owns a condo)

You would still be working less shifts and wouldn’t be in such financial stress but it’s your life.
 
Could you join the group and not join the partnership track for a couple of years?

HH
 
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