PP offer - please advise

[LostResident1]

I am currently a hospital employee, a few years out BC. I work in a small town (no prior connections here, no family, etc). The practice is good with new machines, good support staff, good morale among department, I do a lot of SBRT/SRS/IMRT. I am paid well at MGMA median.

I recently met with a solo rad onc owner in a top large metro where I have friends and family. He operates two practices, bills globally and pays rent to the hospital. He offered me a contract to work for him as an independent contractor splitting pro fees 50/50. The income comes out to the same as my current job. They showed me the books to confirm, I suspect there is not a lot of hypofrac.

The machines are old, neither has VMAT, no 4D CT, no DIBH. The site I will be at mostly does not even have IGRT. They are doing static IMRT with kVs. He says we will upgrade the machines once I get there and get going. He has been clear that he wants me to grow the practice by meeting/greeting docs. He also says I can buy into the technical. The last good doc left the practice a few years ago and since then he has had a revolving door of older/locums types, some of which he has fired.

What I thought would be an easy decision due to location has given me pause due to the practice itself. It would be quite overwhelming to try to re-tool this practice. I know you cannot have everything. Please offer advice/input.

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[medgator]

I am currently a hospital employee, a few years out BC. I work in a small town (no prior connections here, no family, etc). The practice is good with new machines, good support staff, good morale among department, I do a lot of SBRT/SRS/IMRT. I am paid well at MGMA median.

I recently met with a solo rad onc owner in a top large metro where I have friends and family. He operates two practices, bills globally and pays rent to the hospital. He offered me a contract to work for him as an independent contractor splitting pro fees 50/50. The income comes out to the same as my current job. They showed me the books to confirm, I suspect there is not a lot of hypofrac.

The machines are old, neither has VMAT, no 4D CT, no DIBH. The site I will be at mostly does not even have IGRT. They are doing static IMRT with kVs. He says we will upgrade the machines once I get there and get going. He has been clear that he wants me to grow the practice by meeting/greeting docs. He also says I can buy into the technical. The last good doc left the practice a few years ago and since then he has had a revolving door of older/locums types, some of which he has fired.

What I thought would be an easy decision due to location has given me pause due to the practice itself. It would be quite overwhelming to try to re-tool this practice. I know you cannot have everything. Please offer advice/input.

You'll be looking at a minimum of 2-3 months downtime to change out machines one at time once you are in practice there, i am guessing you'll just treat at the other practice while that is happening? Financially, you'll be on the hook for both machines as well. I am guessing that's why he hasn't upgraded already. It's insane in 2022 to not have an igrt/SBRT capable linac and this type of capex should have been planned for and implemented years ago.

Also not clear why he should get to split pro fees with you unless he is doing half the clinical work.

Lots of risks, but possibly rewards as well, including the location you want

 

[RadOncDoc21]

I know for me faced with a similar decision, I chose to not take on the financial risks. I don’t think PP in medicine is the same as it used to be and would rather invest my money into something else vs. establishing a practice unless it was a well-running machine. There are so many bigger fish in the ocean with plenty of resources who have been in the game longer.

 

[jondunn]

you have to know yourself. are you willing to give up the type of tech and the type of clinic you are used to to run a clinic in this setting? it will take a long time for things to change. you're leaving a hospital based practice for the wild west of free standing PP.

you also have to really really really trust this guy, as he has the big time power diffrential advantage even if you are splitting stuff 50/50 pro fees wise. you are earning technical for him and are working for him, in the end.

 

[RADONC4285]

I am currently a hospital employee, a few years out BC. I work in a small town (no prior connections here, no family, etc). The practice is good with new machines, good support staff, good morale among department, I do a lot of SBRT/SRS/IMRT. I am paid well at MGMA median.

I recently met with a solo rad onc owner in a top large metro where I have friends and family. He operates two practices, bills globally and pays rent to the hospital. He offered me a contract to work for him as an independent contractor splitting pro fees 50/50. The income comes out to the same as my current job. They showed me the books to confirm, I suspect there is not a lot of hypofrac.

The machines are old, neither has VMAT, no 4D CT, no DIBH. The site I will be at mostly does not even have IGRT. They are doing static IMRT with kVs. He says we will upgrade the machines once I get there and get going. He has been clear that he wants me to grow the practice by meeting/greeting docs. He also says I can buy into the technical. The last good doc left the practice a few years ago and since then he has had a revolving door of older/locums types, some of which he has fired.

What I thought would be an easy decision due to location has given me pause due to the practice itself. It would be quite overwhelming to try to re-tool this practice. I know you cannot have everything. Please offer advice/input.

Family ties aside, I world stay put if I were in your shoes. You have no guarantees he will upgrade the machines. Even if he does, there are financial risks involved as others pointed out. More importantly, you alluded to a lot of conventional fx treatments. At some point you'll be forced to hypofrac. How will that change your income? No guarantees you'll be able to grow the practice. Lastly, do not under estimate the importance of good support staff, which you seem to have in your current job.

Unless tou think this is the only chance for you to move home and it's an absolute priority for you to do so, stay where you are.

 

[LostResident1]

That's the problem I am facing. I am used to a very modern up to date clinic, I can order any study/test/scan and provide the best possible care. I feel like this is a step backwards into the wild west as you stated. It would take time to upgrade to CBCT and then to add VMAT. I don't think a new machine is in the cards, but rather piecemeal upgrades. I would also be putting my livelihood in his hands essentially. You are correct he would have no obligation to upgrade once I am there, as upgrades really wouldn't increase the bottom line. Also no guarantees I even grow the practice.

 

[Neuronix]

He offered me a contract to work for him as an independent contractor splitting pro fees 50/50.

That's atrocious IMO. He's getting all the technical and should be happy with that. Why does he deserve half of your professional too?

Also, this guy doesn't want to upgrade the equipment because he's just printing money on the old stuff. So you'll be buying this new equipment yourself if it happens at all and giving this guy a piece. Why not just start your own practice?

 

[Ray D. Ayshun]

All those things he doesn't have aren't new. The fact that there is no evidence of an effort to bring things up to modern standards speaks to his intentions I think. When someone tells you who they are, believe them.

 

[heartisinradonc]

How big is skin cancer RT in the US? You could conceivably build your own PP in Australia just on skin if you came in here with enough $$$$$$$$$$. I've been thinking about it. I see MCC at least 3 cases a week here.

 

[RSAOaky]

I would trust your gut on this one. If you're highly motivated and location means a lot then you can make it work, but it doesn't sound like a great situation which is probably why he hasn't been able to recruit a long term replacement. Also, if he's planning on replacing the linac why would he wait until you get there and there's another mouth to feed to do so? It's always hard to give advice knowing only part of the information but if you decide to do it then make sure you have some ironclad guarantees because you are taking on a lot of financial risk by leaving a job you like that pays well to take on one that you probably won't like and has potential to not pay well if something changes in the market.

 

[Ray D. Ayshun]

Also, where is this job and who should I email about my interest?

 

[fiji128]

Definitely some red flags here with keeping the practice 10 to 15 years behind the times and locums/firing docs in a location were that presumably shouldn’t be necessary. I’d maybe try to reach out to some of prior docs who worked there if possible or maybe talk to some of the neighboring rad onc practices to get a better idea what’s going on. Otherwise you could just sign up with the attitude that even if the job is a complete turd and least it gets my foot in the door in a location you want to be.

 

[elementaryschooleconomics]

Red flags, as others have mentioned:

1) He bills global on TWO practices but the offer to you is to SPLIT pro fees 50/50? Wow. Is this a temporary arrangement (pseudo-associate) before you can become a full partner? Because this sounds like you get to do more than half the work for much less than half the reimbursement.

2) He's "talking" about getting new machines? Cool - but what's his PLAN? Has he engaged vendors, secured capital, obtained a CON (if needed), etc etc? If those steps haven't been taken, I'd question the seriousness of his convictions. Even if they have been taken, this is not a quick or easy process.

 

[RadOncDoc21]

Red flags, as others have mentioned:

1) He bills global on TWO practices but the offer to you is to SPLIT pro fees 50/50? Wow. Is this a temporary arrangement (pseudo-associate) before you can become a full partner? Because this sounds like you get to do more than half the work for much less than half the reimbursement.

2) He's "talking" about getting new machines? Cool - but what's his PLAN? Has he engaged vendors, secured capital, obtained a CON (if needed), etc etc? If those steps haven't been taken, I'd question the seriousness of his convictions. Even if they have been taken, this is not a quick or easy process.

In my experience, I’ve come across similar practices where the retiring doc is always trying to milk the new guy/girl as much as they can before they leave. They usually stay on for years and place all the burden on the person and you have to trust they will hand you the keys. I’ve even seen one guy who wanted to wait for “downtime” on the machine before he would replace it but when the machine went “down” it still wasn’t considered “downtime.” He basically held the new machine as a carrot in front that he never was really ever going to address.

 

[BobbyHeenan]

Have you talked to the "last good doc" who left there a few years ago? I would be curious to hear his/her thoughts.

Other things I would want to know:

1. In a world where you collect only pro fees - what are the pro fees of this practice?
2. Related to #1...what happens when/if the hospital just buys this practice out and starts either employing you or taking the technical while you get the professional?

 

[Mandelin Rain]

Hard to leave a good thing for such an uncertain position. To me it sounds like there is no chance at partnership here. Also sounds like you'd be treating below standard of care to maintain profits for him. I'd investigate further, but if not very sure of the answers/written guarantees you get, I'd walk away.

 

[Neuronix]

Hard to leave a good thing for such an uncertain position. To me it sounds like there is no chance at partnership here. Also sounds like you'd be treating below standard of care to maintain profits for him. I'd investigate further, but if not very sure of the answers/written guarantees you get, I'd walk away.

There were many positions like this in my home state when I finished training.

I used to locums for these guys and they all knew who I was. Still, the offers were like this--they took a huge cut of collections, equipment was antiquated, no path to partnership or some gimmicky junior vs. senior partnership that was still very segregated, outrageous technical buy-in valuations, verbal statements that they would never put into writing, positions available for years on end but nobody would take them or stay for more than a year or two, really goofy treatments by the senior doc that they expected you to continue to push the volume and revenue up (tons of fractions, minimal contouring or really suspect dosimetrist contouring, questionable competency). Still, they never forgot that big and punitive non-compete. These are boomers who got in when the getting was good and now want to put someone under them, push as much volume as possible to the junior guy, and collect as much off the new guy while they take it easy in their senior years.

I know this is an unpopular opinion here on SDN, but why not just stay employed if that's the offers you're getting from physician owned practices?

It's not paranoia if they're all out to get you. I hope these positions never fill and a part of me hopes they go out of business as junior people with more know-how and better equipment expand into their areas. With oversupply people get more and more desperate though, and I hate to see people getting taken advantage of.

 

[RickyScott]

Hard no.

 

[TheWallnerus]

Be careful. The independent contractor angle and being 1099’d may not work out to be as financially lateral a move as it first appears.

 

[deleted1111261]

Hard no.

 

[RO28]

It may sound enticing, but I wouldn't do it. I would ABSOLUTELY talk to the prior locums or other docs who previously staffed the clinics as they may provide valuable insight. Speaking from experience, it is incredibly challenging to get someone who has been practicing a certain way for 20+ years to make change, even if it is for the good of patients/group. The amount of stress is probably not worth it and having good support staff where you are at is paramount.

 

[SneakyBooger]

A bird in hand is worth 2 in the bush.

Stay put if you have a good gig, which it sounds like you do.

 

[deleted1116990]

I am currently a hospital employee, a few years out BC. I work in a small town (no prior connections here, no family, etc). The practice is good with new machines, good support staff, good morale among department, I do a lot of SBRT/SRS/IMRT. I am paid well at MGMA median.

I recently met with a solo rad onc owner in a top large metro where I have friends and family. He operates two practices, bills globally and pays rent to the hospital. He offered me a contract to work for him as an independent contractor splitting pro fees 50/50. The income comes out to the same as my current job. They showed me the books to confirm, I suspect there is not a lot of hypofrac.

The machines are old, neither has VMAT, no 4D CT, no DIBH. The site I will be at mostly does not even have IGRT. They are doing static IMRT with kVs. He says we will upgrade the machines once I get there and get going. He has been clear that he wants me to grow the practice by meeting/greeting docs. He also says I can buy into the technical. The last good doc left the practice a few years ago and since then he has had a revolving door of older/locums types, some of which he has fired.

What I thought would be an easy decision due to location has given me pause due to the practice itself. It would be quite overwhelming to try to re-tool this practice. I know you cannot have everything. Please offer advice/input.

At first I read this as you would be splitting pro fees equally with your partner across the practice, which of course is fair and a right way to do things. But reading the responses above it sounds like he wants to take 50% of your pro fees in addition to keeping 100% of his, and everybody is understandably calling that a very bad deal. So you would be generating probably 1.1M in pro but only collecting about 550k. In other words, you would be working a lot harder than you are right now for the same money.

It's curious, that when I lamented about basically the same thing on the private forum (what is a fair percentage of professional fees for practice owners to skim from new hires), a couple of practice owners ripped me apart for basically suggesting the same thing as what has been suggested here (to overwhelming support). In fact, I came to this forum asking a similar question where I had joined a practice where I was making well under 50% of the professional collections I was bringing in with a questionable buy-in arrangement later. Everyone told me that was B.S. and I eventually renegotiated something much more fair (~25% skim seems to be fair so if you're collecting 1M getting paid 700 range would be fair). Yet for some reason, when I tried to pay it forward and suggest that if you were bringing in 1M+ in pro but getting paid 300-400k with no opportunity to have your sweat equity realized in the form of technical ownership later on you were getting taken advantage of, I was patronized and gaslit by a couple of posters that wait that could actually be a golden opportunity and one should be so lucky to make hay for the practice owners. Including someone who claimed to have built a practice who ignored me a while ago when I reached out for advice trying to do something similar (I had land and a linac procured with a partner, but rapidly escalating building costs over the past year shut that project down) but was quick to dispense with bizzare personal criticism. WTF? There are absolutely shady practice owners out there who want to trick people into working for less than what they are worth. The advice I got on this forum truly helped my personal situation, and I'm very thankful for that, and my intent is positive in trying to help my peers avoid exploitative administrators and practice owners as well.

LostResident, in your case, this may not be a terrible opportunity. Opportunities to own a linac and the technical revenue stream in a major metro are extremely rare. In this scenario, unlike my pro-only example above I got chewed out for, your sweat equity might actually be getting you something. If he's near retirement, you can offer to buy a new or newish linac (used Truebeams can be had relatively affordably or at least something that can do the basics you are talking about) at one of the sites to start, and negotiate so that most of the TC from that machine is going to you (since you're on the hook for the loan). If he wants to keep things even and split the cost of the machine with you, then fine, you could still potentially own 50% of the TC of that new machine. There is obviously an enormous amount of risk involved with this for a potentially large payoff, and something you would have to be personally willing to accept. Do you have a family? Other obligations? Debt?

That's all a big IF. Realistically I do agree with the above that more likely he is a greedy boomer that is going to never let you touch the TC and milk the cow he has until it drops dead then sell the corpse to the hospital and say good luck kid the CEO's a good guy I'm sure he will keep you on. But it's worth at least investigating given the rarity of even having the discussion these days.

 

[deleted1111261]

Everyone is right about the "red flags" about the new practice. I'd like to focus on the old practice.

- The pay is good. This is important as this is a job and pay is important.
- The tech is good and they seem committed to keeping it that way
- You appear to be enjoying the work there. Super important as you are indicating concern about practice style/pressure to conform there.
- Staff is good. This is sooooo important and underrated.

These 4 factors are 4 of the 5 things about a job I would look at it. 5th is Community. I.e. - family + friends + city + support. For many people, community will trump the rest and you gotta do what you gotta do. If this is high priority and an urgent need, you may want to see if you can take the job but have an out (no non-compete, no payback if you leave early) and bail when you find something better.

If you can wait a bit, then wait it out. Things always evolve and positions open up. Timing is absolutely everything. The moment I take a new job, it seems like a practice that I was waiting for has an opening or I get a call from a friend asking if I'd like to join. So, take your time. You have a good situation, except for Community. For many (including me at this stage of my life), this is of utmost importance, but most people can wait it out.

 

[elementaryschooleconomics]

It may sound enticing, but I wouldn't do it. I would ABSOLUTELY talk to the prior locums or other docs who previously staffed the clinics as they may provide valuable insight. Speaking from experience, it is incredibly challenging to get someone who has been practicing a certain way for 20+ years to make change, even if it is for the good of patients/group. The amount of stress is probably not worth it and having good support staff where you are at is paramount.

To piggyback - you also have to watch out for the support staff in this environment.

Normally, high staff turnover is a red flag. However, if you have a Boomer RadOnc who has been doing things the same way since the 90s: watch out if the staff has also been with that doc since the 90s. The nature of our job puts us at the mercy of therapists and Dosi/Physics.

So if you have a whole group of people who have never worked anywhere else, with a doc who hasn't updated their techniques in 20+ years...good luck.

 

[deleted1116990]

To piggyback - you also have to watch out for the support staff in this environment.

Normally, high staff turnover is a red flag. However, if you have a Boomer RadOnc who has been doing things the same way since the 90s: watch out if the staff has also been with that doc since the 90s. The nature of our job puts us at the mercy of therapists and Dosi/Physics.

So if you have a whole group of people who have never worked anywhere else, with a doc who hasn't updated their techniques in 20+ years...good luck.

There seriously needs to be a support group for new grads who took over a boomer's practice with staff that have been there for 20+ years.

I have worked in that environment. They are the family of brothers and sisters. Dad left and you are the new boyfriend mom is dating.

I have also worked in an environment where staff were severely underpaid and turned over every 6 months. They just did whatever you asked them to do and were super chill. They were all young and didn't care and only there until they could find something that paid higher.

 

[RO28]

Agree with Elementary and Simul. If you are relatively happy and have a good gig where you are at, then waiting for an opportunity in your home location could be worthwhile (and spend the time now to work on building those connections). I really do understand the community trumping everything else on that list, but it has its drawbacks. Like you I am a couple years out, BC and have experienced some challenges with my current position that I want to make others aware of. PM me if you want to chat more.

 

[RSAOaky]

At first I read this as you would be splitting pro fees equally with your partner across the practice, which of course is fair and a right way to do things. But reading the responses above it sounds like he wants to take 50% of your pro fees in addition to keeping 100% of his, and everybody is understandably calling that a very bad deal. So you would be generating probably 1.1M in pro but only collecting about 550k. In other words, you would be working a lot harder than you are right now for the same money.

It's curious, that when I lamented about basically the same thing on the private forum (what is a fair percentage of professional fees for practice owners to skim from new hires), a couple of practice owners ripped me apart for basically suggesting the same thing as what has been suggested here (to overwhelming support). In fact, I came to this forum asking a similar question where I had joined a practice where I was making well under 50% of the professional collections I was bringing in with a questionable buy-in arrangement later. Everyone told me that was B.S. and I eventually renegotiated something much more fair (~25% skim seems to be fair so if you're collecting 1M getting paid 700 range would be fair). Yet for some reason, when I tried to pay it forward and suggest that if you were bringing in 1M+ in pro but getting paid 300-400k with no opportunity to have your sweat equity realized in the form of technical ownership later on you were getting taken advantage of, I was patronized and gaslit by a couple of posters that wait that could actually be a golden opportunity and one should be so lucky to make hay for the practice owners. Including someone who claimed to have built a practice who ignored me a while ago when I reached out for advice trying to do something similar (I had land and a linac procured with a partner, but rapidly escalating building costs over the past year shut that project down) but was quick to dispense with bizzare personal criticism. WTF? There are absolutely shady practice owners out there who want to trick people into working for less than what they are worth. The advice I got on this forum truly helped my personal situation, and I'm very thankful for that, and my intent is positive in trying to help my peers avoid exploitative administrators and practice owners as well.

LostResident, in your case, this may not be a terrible opportunity. Opportunities to own a linac and the technical revenue stream in a major metro are extremely rare. In this scenario, unlike my pro-only example above I got chewed out for, your sweat equity might actually be getting you something. If he's near retirement, you can offer to buy a new or newish linac (used Truebeams can be had relatively affordably or at least something that can do the basics you are talking about) at one of the sites to start, and negotiate so that most of the TC from that machine is going to you (since you're on the hook for the loan). If he wants to keep things even and split the cost of the machine with you, then fine, you could still potentially own 50% of the TC of that new machine. There is obviously an enormous amount of risk involved with this for a potentially large payoff, and something you would have to be personally willing to accept. Do you have a family? Other obligations? Debt?

That's all a big IF. Realistically I do agree with the above that more likely he is a greedy boomer that is going to never let you touch the TC and milk the cow he has until it drops dead then sell the corpse to the hospital and say good luck kid the CEO's a good guy I'm sure he will keep you on. But it's worth at least investigating given the rarity of even having the discussion these days.

I think this is a bit of a different situation. This doesn't sound like a healthy practice with a strong referral base, good equipment, a clear path to partnership, etc. This is an older doc with old machines and a revolving door of locums and bad physicians skimming a large percentage of pro fees with a vague possibility of partnership doing protracted fractionations looking for someone to "come in and build the practice." It's a high risk low reward situation unless there's a very clear and fair path to technical ownership in which case it's a high risk high reward situation.

 

[deleted1116990]

I think this is a bit of a different situation. This doesn't sound like a healthy practice with a strong referral base, good equipment, a clear path to partnership, etc. This is an older doc with old machines and a revolving door of locums and bad physicians skimming a large percentage of pro fees with a vague possibility of partnership doing protracted fractionations looking for someone to "come in and build the practice." It's a high risk low reward situation unless there's a very clear and fair path to technical ownership in which case it's a high risk high reward situation.

I agree, it is very risky. At the same time, I don't think opportunities in major metros of people being handed 50% global billing on a platter really exist or at least should be a reasonable expectation. If he really wants to be in this location and wants the option of ownership, he may not be presented with any other options in his career given the job market, unfortunately.

It may be reasonable to try and negotiate an eat-what-you-kill pro-only non-partnership track with the understanding that boomer will always collect the TC or negotiate a clear path to ownership with the lower pay up front as sweat equity. Given that the linacs need replaced, negotiating a split on the purchase of the new machines and the billing seems like an easy way to do this, especially since the boomer probably doesn't want to invest further in the practice that's already generating fat dividends for him.

Even having a job opportunity, ANY job opportunity in a major metro is rare. Boomer surely knows this and can choose to exploit the young in the field if he wants to and lacks ethics. Since you already have a decent job, you don't have anything to lose other than pissing him off and yanking a job offer that you wouldn't have wanted without one of the above negotiations anyway.

 

[RadOncDoc21]

Always choose job over location… I can’t stress that enough. Hopefully, you will get both but a bad job will always win out despite all the pretty beaches and biryani.

 

[evilbooyaa]

I agree, it is very risky. At the same time, I don't think opportunities in major metros of people being handed 50% global billing on a platter really exist or at least should be a reasonable expectation. If he really wants to be in this location and wants the option of ownership, he may not be presented with any other options in his career given the job market, unfortunately.

It may be reasonable to try and negotiate an eat-what-you-kill pro-only non-partnership track with the understanding that boomer will always collect the TC or negotiate a clear path to ownership with the lower pay up front as sweat equity. Given that the linacs need replaced, negotiating a split on the purchase of the new machines and the billing seems like an easy way to do this, especially since the boomer probably doesn't want to invest further in the practice that's already generating fat dividends for him.

Even having a job opportunity, ANY job opportunity in a major metro is rare. Boomer surely knows this and can choose to exploit the young in the field if he wants to and lacks ethics. Since you already have a decent job, you don't have anything to lose other than pissing him off and yanking a job offer that you wouldn't have wanted without one of the above negotiations anyway.

^^ It's not 50% global billing. It's 50% of pro-fees. Boomer is keeping all the technical. Boomer wants a sucker to get involved with debt/risk on an a machine upgrade rather than upgrading it himself to something that would be considered SOC at least 5, if not 10 full years ago.

This guy is a snake until proven otherwise, IMO. Only way this makes sense is to have a clear path to a portion of technical (aka global billing).

However, using it as a launching pad to the city/region you want to be in is not unreasonable, as Simul mentioned. I know 1 person who did this - went to a highly desireable area they had no connections in with a crap job with a similar boomer set-up that was built as a churn and burn, built local connections once they arrived (they had a contact locally who could assist), and bounced out of that crap job within the next 1-2 years into a 'better' job.

Most of the money in the world is not worth the red flags this practice is throwing up, IMO, especially if it comes with any risk. Doing it all for an equivalent income (which, if you're a 1099, actually means you're taking a pretty massive pay cut compared to your W-2 salary with benefits). If you wanted to use it as a potential launching board into the region mentioned.

For some people, the importance of living close to family cannot be overstated. And that' sOK if you are, then this might be worth it. But, if you're not one of those people, and are otherwise happy with the job, and the city/region where you currently live, I'd probably stay put.

 

[RSAOaky]

I agree, it is very risky. At the same time, I don't think opportunities in major metros of people being handed 50% global billing on a platter really exist or at least should be a reasonable expectation. If he really wants to be in this location and wants the option of ownership, he may not be presented with any other options in his career given the job market, unfortunately.

If you're a small practice in a major metro area it's a race to who gets bought out first. If local mega-hospital buys YOU out, everything goes well. If instead they buy your referring medoncs out, and the referral tap dries up, then you're suddenly up ****'s creek.

 

[Ray D. Ayshun]

Flaccid no.

 

[yesmaster]

So the OP’s big city job offer sucks, my question is if there’s any way to build your own practice? The big city has the patient volume if the boomer has 2 practices, and it wouldn’t be too costly to get equipment that’s better than the boomer’s. If the big city has young med onc’s, they probably don’t love that their patients are off to XRT for months.

 

[deleted1116990]

^^ It's not 50% global billing. It's 50% of pro-fees. Boomer is keeping all the technical. Boomer wants a sucker to get involved with debt/risk on an a machine upgrade rather than upgrading it himself to something that would be considered SOC at least 5, if not 10 full years ago.

I was talking about a hypothetical where somebody would be made a full partner in major metro and split global. I'm aware this situation is far worse that boomer wants to skim 50% of pro. And without IGRT and stereotactic, I actuallyquestion the income projections that boomer is claiming that he will make the same as MGMA median with a 50% pro skim.

Of course, if boomer wants LostResident to pay for machine upgrades but is not going to pay out a commiserate portion of TC through fractional ownership of the machines, then yes hard pass. Boomer can write a check tomorrow and cover that himself if he wants but wants a 35 year old still trying to pay back student loans to shoulder that cost for him and provide him with the reward. I am in agreement that this is the most likely scenario but am simply saying leave sniff it out and do your due diligence. The difference here vs. the pro-only situation on the private forum is the opportunity for technical collections. That changes the calculus slightly in terms of the risk in accepting a crap upfront deal (especially factoring in a desirable location). I am unclear based on his post what exactly boomer is proposing and would be willing to agree to with regards to this, but I would not get my hopes up.

 

[metallica81788]

There are way too many hypotheticals, what-ifs, and "negotiations" in whatever model that has this new position working out. Not worth the risk.

 

[deleted1116990]

So the OP’s big city job offer sucks, my question is if there’s any way to build your own practice? The big city has the patient volume if the boomer has 2 practices, and it wouldn’t be too costly to get equipment that’s better than the boomer’s. If the big city has young med onc’s, they probably don’t love that their patients are off to XRT for months.

You would really be taking risk to the next level in that scenario.

I have looked into this a lot. Specifically in Florida.
My conclusion was that it was better to start a practice in a less competitive environment. Your risk becomes lack of volume due to competition for referring doctors to lack of volume due to population base.
And then there is the problem that physically building anything right now is stupidly expensive from a money and time standpoint.
If anybody wants to convince me otherwise, PM me.

 

[Reaganite]

I started somewhat similar to OP many years ago, took a chance, and ended up building a practice that changed my life forever. It's extremely risky, most will not have the business savvy to do it, and knowing what I know now I laugh at myself for being so "naive" to have ever considered the position. That being said, there will almost never be a sure-thing PP gig with some chance of ownership in a major metro. The first thing you should ask yourself is: do you have the personality and drive to build a practice? If not, the other stuff is irrelevant because you will not be able to make a PP in an uber competitive metro area work.

 

[thecarbonionangle]

Man the thought of going to a place with no 4dct (some have it but dont use it), no sbrt, no vmat, terrible dosimetry/physics/support, inbred staff who have been under boomer ways for decades, gives me chills. I know these places are out there because i salvage their failures. Almost always it is a white male boomer who should have retired decades ago.

it is impossible to fix this culture unless you clean house. Boomer will never leave and die on throne. This whole story is really ringing my hellpit bell. You have been warned.

 

[medgator]

Man the thought of going to a place with no 4dct (some have it but dont use it),

You still using it on your N3 lungs and head and necks, carbon? Just wanted to check in

 

[thecarbonionangle]

You still using it on your N3 lungs and head and necks, carbon? Just wanted to check in

All im saying is that some folks out there need to learn 4dct. Im sure you know some out there, have heard of some. Im sure some hellpit will open up a fellowship on it once we quantify the need.

 

[jondunn]

All im saying is that some folks out there need to learn 4dct. Im sure you know some out there, have heard of some. Im sure some hellpit will open up a fellowship on it once we quantify the need.

it takes a village!

 

[jondunn]

You still using it on your N3 lungs and head and necks, carbon? Just wanted to check in

head and neck????

que?!

 

[medgator]

head and neck????

que?!

Some people really love it! I get doing it for an N3 with a big mass out in the periphery, but a bulky mediastinal N3 with a pancoast tumor in a symptomatic pt? Ain't getting a 4DCT in my practice

 

[jondunn]

Some people really love it! I get doing it for an N3 with a big mass out in the periphery, but a bulky mediastinal N3 with a pancoast tumor in a symptomatic pt? Ain't getting a 4DCT in my practice

Sounds like OPs practice is for you!

No 4D, no problem!

 

[medgator]

Sounds like OPs practice is for you!

No 4D, no problem!

Not all of us get protons for breast, bro

 

[jondunn]

also it doesn’t seem that OP is saying he has to give half
The pro fees to the owner but rather he and the owner will
Split total pro fees 50/50.

But stay away I agree

 

[Ray D. Ayshun]

Some people really love it! I get doing it for an N3 with a big mass out in the periphery, but a bulky mediastinal N3 with a pancoast tumor in a symptomatic pt? Ain't getting a 4DCT in my practice

You don't 4d stage 1 true glottic? I like to keep my stamp so small you could only send a postcard. Gotta know where that sucker is.

 

[Neuronix]

also it doesn’t seem that OP is saying he has to give half
The pro fees to the owner but rather he and the owner will
Split total pro fees 50/50.

But stay away I agree

Oh maybe I misread it. My apologies if so. If that's the case it may not be a bad deal assuming the work is split approximately 50/50.

 

[jondunn]

You still using it on your N3 lungs and head and necks, carbon? Just wanted to check in

Is this a training era thing? Why do you refuse to use 4D? It doesn’t make sense. Old dogs can learn new tricks!