Currently in fellowship doing bread/butter procedures (MBB, epidurals, PNB, few SCS/PNS trials, etc.) and just interviewed at a private practice spot where they do a lot of procedures that I will have not done any training in prior to graduating (e.g. IT pump, SI fusion, Vertiflex, Kypho, MILD, Discectomy, lots of SCS/PNS trials etc) and significant amount of "OR pain procedures" at a very busy practice seeing 30-40 pts/day - how many of you are commonly performing these procedures and are these procedures "justified" from an evidence and insurance standpoint? Also concerned about learning curve for these procedures jumping straight into a job like this as I would not be comfortable performing those procedures.
private practice concern
- Thread starter mtu620
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unless ur getting 750k don’t take this job . u have some months of fellowship left , seek out these chances, spend a few days of fellowship with these docs and see how it runs before u sign up. U may be able to learn a few things too. all procedures are relatively ok as long as you know ur anatomy...
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Can you ask them to proctor you?
From a brief conversation they said would have no problem proctoring/training me in these procedures.
One day / wk OR pain procedures.
One day / wk office based procedures.
I also would have to commute 1hr each way.
I'm not too familiar with compensation models at this point in my career but the dude said something like either guaranteed base (300 vs 400k) or keep 60% of what you earn - good/bad/thoughts?
if you have good hands and good knowledge of anatomy you can learn any of these after fellowship
they are worth having in the toolbox
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I would agree. In my fellowship with some very capable attendings with various backgrounds, they don't do this - Vertiflex, kyphos, IT pumps (the implants), SI fusion. For a number of these things, including vertiflex it's not covered by insurance, IT pumps can be a pain in the butt if complications, and the risk in my opinion is not worth the squeeze. For a lot of the production based compensations too i fthe insurance takes back payment you will have worked for free as the group will likely take back the payment they gave you. I would say that some of these procedures seem gimmicky - for example Vertiflex. I also don't think the average fellow is exposed to this in fellowship, bc these things are not typically covered by insurance therefore not taught. You also have to think to yourself whether you want to stat at a practice where you will already have a high learning curve - per what every attending has said, you learn a lot during your first year out and need some time to settle your skill set, so having to learn a bunch of new procedures doesn't seem wise.
Maybe as you progress and are more comfortable you can start learning these things.
On a different topic and sorry to hijack - not trying to hijack this thread - what do you all think about a salary vs. equity type position in a group? I have been offered a supervisory type position (kind of as a side gig) for supervising peripheral type injections - PRP, etc. w an offer of equity vs. salary.
Thoughts?
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First make sure if it's 300 or 400k - big difference there. Also i would say initially you want a stable base bc you don't know what your patien tbase will be like how many people you'll see, how long your collections will take. The 60% you also have to find out if it's of gross collections vs out of net collections - ie - after expenses. So if you bill and collect 1 million dollars, and are left with 500k after expenses, do you take 60% of the 500k or is it 60% of the 1million you bill? Makes a big difference. Pain has high overhead adn surgical even more. So beware.
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Seeing 30 clinic patients a day is not busy for private practice....I know docs who try to see upwards of 50. Not that you should do that, but adjust your expectations on what is expected of you if you are going to be working for someone else. A big busy practice will not take the time to teach you and set you up properly.
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Take an general anesthesia job and make more money, can do pain on the side
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Wow,
Seeing 30 patients is very busy but doable with good EHR/staff. I feel better at 25 that I actually thought about these human beings that came to me for help.
I don’t know how someone sees 50 patients a day, that’s like 8 min per patient.
Quality care, for sure....
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Everyone is different, but if you cannot see more than 20 in a day you need to be in academics or the VAMC.
Anyone seeing more than 40 is doing a crap job. Unless they work 12hrs.
Anyone seeing more than 40 is doing a crap job. Unless they work 12hrs.
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I would disagree with 20. There are definitely private practice docs seeing more complicated patients that see 20 per day. I expect drusso and ligament are closer to 20 with some of the tough patients they see.
Easier to do around 25 or more if 95% are bread & butter spine cases.
Academics and the VA are more like 15 patients per day.
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When you say "OR cases", am I correct in saying you mean in the ASC the practice owns? That would explain the high volume of these procedures.
30-40 office visits per day is busy, but not unreasonable for a private practice, especially if you are talking repeat patients and handle opiate medications.
If it's the procedures that scare you, don't worry. If you are willing and they can teach you, you'll be fine. If anything, it's good to have a group of people that do these procedures in house before you start so you can bounce questions off them and get help if you run into any problems.
As far as what is "justified", that's a complicated question. Could be completely justiifed and they just built their practice that way, but could be just a money-maker plan with little true good patient care. No real way to determine this without shadowing a few days in the office.
I would not do straight collections right away in a group like this without knowing more. So many ways for them to screw you. I think a salary base first year or two with a bonus based on collections above base and conversion to pure collections based payment year 3 is completely reasonable.
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1hr commute sounds horrible for that kind of pay.
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I'd clarify the 60% and go that route. With the type of volume they are doing, that is a lot of money. See what % of the facility fee you get from the ASC, and ask about share purchasing opportunities. This type of practice sounds very midlevel heavy; this kind of volume is churn and burn; not about patient care. Be sure you are good with that.
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Very kind of you but I think I'm right in the middle range of difficult patients based on what I see posted on here. Regardless, I could not handle seeing more than 25/day max of my typical patient. I usually see less than that. I'm probably slow.
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Fwiw, I recently moved from a 35-40 patient day practice with lots of opiates to a max 24 per day practice with almost no opiates. My life is 1000% better
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Wow, I see about 20 a day. 18-22 depending on no shows and to some extent filling schedule. I have fairly little help so I do all orders, notes, and my current MA anticipates very little.
I feel busy if over 20. Probably all perspective and I spend longer than I need to with patients. I do maybe 1 or 2 pain pill patients a day.
I feel busy if over 20. Probably all perspective and I spend longer than I need to with patients. I do maybe 1 or 2 pain pill patients a day.
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I have fairly little help so I do all orders, notes, and my current MA anticipates very little.
Not a difficult problem to figure out. Add 10 patients to your schedule by hiring scribe to do non physician work.
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I could.
I'm happy currently, get to do what I want and practice as I see fit. I make 25% mgma but work 4.5 days a week. I make enough (wife is also a physician). I could improve efficiency for sure. Would love to see 25 a day and go to 4 days a week.
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Cost of hiring and training scribe or MA. Even if 5 more patients per day this will increase your pay and decrease your stress.
AdminPatient
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60% of collections isn’t bad as long as your payer mix isn’t awful- how much Medicaid?
Who pays your malpractice? Do you have a tail?
How long is your guarantee? I’m assuming you can structure your comp to be: the greater of $400k or 60% of collections. Due to AR lag, you may not exceed that 400k figure in the first year so might want clarity around the time period for measuring collections
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I agree that it depends largely on the setup. I finally got a scribe after asking for many years and realize how much of a difference it makes for me as far as time to get through visits. Having someone do more than take a set of vitals would also make a huge difference-maybe some day Ill have that too. I am always going to spend more time with my patients than the average pain doc, but the more of the visit you offload to other people the more people you can see it is pretty straight forward math.
OP: Personally I would definitely be looking at something different. If you have a strong appetite for advance procedures, you probably won't get a chance to learn those very well outside of a practice like this. On the flip side, outside of stim it is pretty rare that I am recommending any of these, and am generally suspect of other pain *Cough injectionalologi$t$ Cough* doctors that are churning out 40 patients a day to do these.
OP: Personally I would definitely be looking at something different. If you have a strong appetite for advance procedures, you probably won't get a chance to learn those very well outside of a practice like this. On the flip side, outside of stim it is pretty rare that I am recommending any of these, and am generally suspect of other pain *Cough injectionalologi$t$ Cough* doctors that are churning out 40 patients a day to do these.
