redsoxdave

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I was just curious how those of you who have had the experience of choosing private practice vs. joining a group came to the conclusions you did. I guess more simply...what's the positives and negatives of going into private practice straight from residency vs. joining a group. Is it still possible to go private straight from residency considering the costs? How have those of you who have gone straight into private practice gone about it? Any further info would be appreciated!
 

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By PP v joining a group do you mean solo vs group practice? Or vs hospital employee? There are many different types of practice models - Solo PP, group PP, multispecialty group PP, hospital employee (solo and group), academic, etc.

Which, specifically, are you looking at. Each has benefits and drawbacks.
 

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As an aside to this quesiton, how feasible is it to set up a joint academic/private practice gig? I love to teach and I dont want to give that up by doing private practice. I also dont want to be too immersed in administrative crap and lab work to do solely academics.
 
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redsoxdave

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I was thinking solo private practice versus group practice but for the sake of ignorance (my own of course) why not address hospital employee as well. It seems that private practice seems financially difficult considering initial overhead costs such as staff, equipment, software, and electronic records (if you go that route), etc
 

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I think the confusion is your perception that "private practice" means "solo practice". It doesn't.
 

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My 2 cents from my own story.

I wasn't looking for a solo opportunity, but when I interviewed in my eventual area, the opportunity was too good to pass up. I was offered a guarantee by the hospital, although I was to be a solo guy--not salaried by the hospital. They cover me for a year and I pay them back with time for loan forgiveness. IMO, that is really the only way to do this unless you have significant cash resources. I didn't.

Benefits v Risks of solo: You're the boss. I cannot tell you what a huge amount of freedom that brings. I love it. You get all benefit, but you do take all the risks. It's sink or swim. You blow a case in your first month in a big way, and you're toast. Being the boss means the office is yours to design, run, change, and invest in how you see fit. The drawback is you've got to learn business. If you don't learn business you're a gonner unless you get lucky and have enough cash on hand to get a well-experienced office manager who can do all that for you. Still you need to learn it so they don't take you for a ride, something that happens far too often. Be prepared to skimp. Also be prepared to be scared out of your mind for a few months until your rep allows your referrals to build. Market, Market, Market your practice. ALWAYS be available. NEVER say no to anyone or any referral--even if you'll lose money on the visit. This will buy you loyalty from the PCP. Make absolutely sure your consultation note is exceptionally well written and thankful to the referring doc. If you have good notes, they'll love it. Make the patient feel like they've got your undivided attention and the best care available. NOTHING will make or break your practice more than word of mouth--especially when the pt reports back to the PCP.

As far as hospital employee situations go. You trade security for freedom. For me, I'd never go that route. You'll be a ***** for an administration that could care less about you. This is less true in an academic setting. I may sound harsh in my summary of this route, but as more and more docs do this, I see more and more docs who get screwed in some way about it. It definitely provides security in the face of declining reimbursement, but you also end up having to tow the party line whether you agree with it or not. I've seen a significant number of docs pull out of their hospital-owned practice for this reason.

As far as joining a group, what you get is less freedom--you'll be an employee for a year or two usually. You'll be told how the practice works and have little input into changing much about it, at least from an administrative standpoint. However, you'll build a busy practice far faster, you'll have a more secured income. You'll have access (hopefully) to more extravagant equipment than you could secure on your own. You'll have a built-in referral network, built-in staff, built-in insurance network. All of these have their own ups and downs.

As far as Academics goes, let's just say that could vary so widely between institutions I can't even begin to address it.

Having a mixed practice is possible. Many people do it. I did it for 3 years while I was in the Air Force. You're never fully accepted as a "faculty" member, but you do tend to find the residents like you more than their own--at least I did. I was much less malignant to them and let them be primary far more often. Also, I didn't make them do all my scut work. Mostly because I didn't trust them enough. I had enough misses from jr residents as a chief, that I double check everything anyway. I enjoyed that and miss it a lot.

Now, after only having a solo practice for a short time, I am merging with another practice. Two reasons. First, is to improve market competition. The person I'm joining with is, in mine and many other opinions, the most well-respected ENT around me in terms of quality of care. We graduated at the same time and practice very similar styles and our likes and dislikes in terms of surgeries and interests compliment each other well. Second, is security. We both would like to share call and share cases. We both would like to secure referral patterns and feel our reptutations will lock that up nicely together. We'd like to be able to share pt care more efficiently. If there is something I do well, I'll take the pt. If there's something I don't do well, I'll have a partner who can take up my slack. Patients get the best care that way without losing out on financial benefits.

So, I started solo and love it. However, to really grow, particularly in the market I'm in, I found a wonderful opportunity to merge which will only further my practice and as a nice corollary my earning potential. If this particular doc wasn't so awesome, I doubt I'd be getting a partner so quickly. In fact, I've turned 2 down this year for that reason.

So that's my 2 cents. Or 2 bucks as it turns out.
 

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resxn as always is much more loquacious than I will be. I joined one other guy and am very happy with the situation.

I really liked NOT having to make all the business mistakes during that first year. Instead, I can learn the biz side of things, knowing that my partner had 20 years of experience and could teach me some things.

Like resxn, I took a recruiting agreement from a hospital. Basically these are safety nets, but took away a lot of anxiety about paying the bills during the first year.
 

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Can anyone comment on how common student loan repayment benefits are in these situations? What are some common packages you saw in this respect? Is it only offered in "undesirable" areas? Put another way, how hard would it be for someone $250k in debt to get loan repayment for working with a group for 5 years.
 

TheThroat

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Can anyone comment on how common student loan repayment benefits are in these situations? What are some common packages you saw in this respect? Is it only offered in "undesirable" areas? Put another way, how hard would it be for someone $250k in debt to get loan repayment for working with a group for 5 years.

I was given the salary guarantee but was given no help with loans. The hospital just told me that I could do whatever I wanted to do with the salary.

My financial guy tells me just to pay them off over time. My student loans have such a low interest rate that paying them off slowly makes more financial sense than trying to put in blocks of cash early on. His point was that with inflation steadily climbing over time, low-interest loans actually become almost no-interest in 10-20 years. Better to invest the money that you would use to try to pay them off early.
 

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When I was looking for positions there were 2 types of opportunities for loan forgiveness. One was with a desperate group situation. These could be practices in good locations, but the practice was suffering and needed new blood to help turn it around. The practice might be in a less-desirable location (i.e. rural) which then would need extra incentives to extract good candidates.

I found the same was true for hospitals. Good location with desperate need for docs--usually because that institution was not considered a "go-to" place in the community. Or not so good location, but desperate need to get docs to the area.

Unfortunately, the highly desireable locations and practices and hospitals don't need to offer incentives to attract candidates. The location is all the incentive they need. Every once in a while you'll find someone who got to have their cake and eat it too, but it's not often.
 

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What kind of time commitment are we talking for those?

Mine was a 1 year guarantee with loan forgiveness over 3 years. Basically 1/36th of the total is forgiven for each month I stay in practice in their designated area.

If I choose to leave, I owe whatever hasn't been forgiven to that point.
 

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This seems like a good thread for me to jump in and ask a few questions. I am a PGY-4 just starting my job search. Location is my top priority (or at least my wife's top priority). So far I've only found a couple of opportunities in the city we are looking to live in, both with multi-specialty groups. One is quite large with at least a few ENT's already in the group. The second seems to be smaller with mostly primary care and some neuro and OB, but does not have any ENT currently but looking to add this. I was wondering what opinions you have about multi-specialty groups. What advantages and disadvantages are there vs. single specialty? Any red flags about the latter situation I described? What should I ask or beware of? Also do you have any advice about working with a recruiter? Any advice you can provide would be greatly appreciated.
 
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resxn

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I was wondering what opinions you have about multi-specialty groups. What advantages and disadvantages are there vs. single specialty? Any red flags about the latter situation I described? What should I ask or beware of? Also do you have any advice about working with a recruiter? Any advice you can provide would be greatly appreciated.

Great questions. Here's my thoughts:

I - Multi-specialty group
a - advantages include:
1 - built-in referral network
2 - built-in capital for setting up the practice
3 - often secure salary position
4 - generally a wide-range of resources esp in the larger groups
5 - usually an already well-demonstrated need for the new guy
6 - usually benefits are available--401k, health plans, etc.

b - disadvantages include:
1 - as a surgical subspecialist you end up subsidizing the group. In other words, you will be providing a greater profit margin than the PCP's will be, but as a partner, when you make it to that level, you get equal share of the profit. Thus, PCP's benefit more financially from the arrangement than you do. Now if there is a compensation built in so that your share of the profit is larger if your contribution to the profit is greater, it's a good situation.
2 - You're not the boss. And sometimes, a non-surgical person is the boss. And sometimes that non-surgical person is less interested in you than his own. Similar to the situation in which the ENT is not a dept with it's own chairman, but rather a division of general surgery.
3 - limited growth potential for salary
4 - less autonomy to set your own hours, your own OR schedule, your own clinic load. Often these are dictated to you or at least you are pressured into what's best for the group, not just you.
5 - less autonomy to get what you want, more often have to settle for what you need. Unless the MSG is loaded, then it's great.
6 - you'll always start as low man on the totem pole

II Regarding a small MSG with no ENT in place. Check hard into their resources. You want to make very sure that they are able to purchase or lease the basic equipment you need. Who oversees your clinic? Who is your boss? Is it a family practice doc? Do they already have some other surgical specialties? Or are you the first? What do they envision your role to be? What kind of staffing can they provide? Who runs your books? Will you have your own clinic, or will you share with a non-ENT physician? Can they do audiology? allergy? How much money do they have to get started? What is the reimbursement situation--eat what you kill or everyone takes an equal share of the pie? EMR in place? Are they planning on putting one in place? What happens if profits are short for payroll one month--do they have cash calls (where you have to give back a certain amount to make sure that you cover the salary for your receptionist)? What kind of benefits do they offer?Those are the questions I'd want to know.

III Be wary of recruiters. They get paid by getting docs hired. As Reagan said, trust but verify. They usually embellish, but rarely do they lie. They also tend to work for places that are more desparate which could be good or bad depending on why those places are desparate. It's just the truth that desirable locations and desirable practices just don't need recruiters.
 

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Thanks resxn for your detailed response! Although I was aware of some of the things you stated about MSG's I feel much better informed now.

To this point my job search has been fairly passive. I've replied to a handfull of postings online and then been inundated with phone calls and emails from recruiters. Most of them seem disappointed when I tell them my geographic requirements/preferences, although one has seemingly put forth some effort to explore the market. My next question would be, since I know where it is that I want to live, and considering your comments regarding recruiters, should I start contacting groups/doctors myself to find out if they are looking for or considering adding another physician to their practice? Do you have any suggestions for my job search? Thanks again for your input.
 

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Thanks resxn for your detailed response! Although I was aware of some of the things you stated about MSG's I feel much better informed now.

To this point my job search has been fairly passive. I've replied to a handfull of postings online and then been inundated with phone calls and emails from recruiters. Most of them seem disappointed when I tell them my geographic requirements/preferences, although one has seemingly put forth some effort to explore the market. My next question would be, since I know where it is that I want to live, and considering your comments regarding recruiters, should I start contacting groups/doctors myself to find out if they are looking for or considering adding another physician to their practice? Do you have any suggestions for my job search? Thanks again for your input.

I was in a similar situation to you when coming out of residency, in that I was looking for a relatively small geographic location. This is what I would do:

--Look up all the hospital systems in the area on the internet and check if they are recruiting for an oto.
--Write a cover letter to every practice in the area and attach your CV. I would try to make these as personal as possible, not just having a letter that says, "To whom it may concern".
--Call all the hospital systems in the area and find out if they have a physician recruiter (most do). Talk to them and emphasize that you are looking to come into the area. A lot of hospitals will then contact their local otos and let them know you are looking.
--Call all the local practices and ask to speak to the administrator. Ask them if they have received your letter and CV. Ask them if they know if the practice is looking to add another physician.

I would be prepared for opportunities to open slowly. I would be very leery of big up front money. The real question is whether the practice will be a good one in the long term. A lot of practices are willing to add a doc IF the right one comes along.

As far as MSG's, I would be very skeptical. MSG's usually do not allow surgeons to capture their full earning potential and often limit your ability to capture income from ancillary sources (allergy, audiology, imaging, etc), but are also usually require less "business" work (hiring, marketing, etc).
 

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Couldn't agree w/ TheThroat more. If you're locked into an area, the way to get into it is simply follow what he said.

Having said that, I have found myself in a highly desireable area. There are 3 new hospitals being built within my city limits--ridiculous. 2 are small (<100 bed) specialty hospitals. One is a gigantic 13-story monster (it will open with only 4 floors). Because of this growth (the population has tripled in 8 years), there are 3 ENT's opening shop in my city this summer. Two who are moving in from places where they already had practices and one coming out of residency. 2 are each joining separate practices, 1 is opening up a solo shop.

I think that for these new people, life is going to be hard for a while. It took me 6 months to get busy, and they told me that was fast. With 3 new guys drawing from the same pool of patients and me still building, it will be a slow process.

The reason I say that is to just say that it's ok to have your heart set on a geographic region, but just be prepared to sacrifice a little if it's a saturated market.
 

blz

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another question to add to the mix:

Does going to a top residency (hopkins, meei, etc.) make a difference in joining a private practice group? It's pretty well-known that it helps for getting academic positions, but does it help at all with attaining a desirable private practice gig? would it help to get a good private/academic type of setup as well?
 

resxn

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another question to add to the mix:

Does going to a top residency (hopkins, meei, etc.) make a difference in joining a private practice group? It's pretty well-known that it helps for getting academic positions, but does it help at all with attaining a desirable private practice gig? would it help to get a good private/academic type of setup as well?

I'd like to hear from TheThroat on this one since he went to one of those top tier programs, but my impression is that it doesn't for private practice for the most part. I think it might if you're dealing with an uber-competitive group in a ridiculous location like Beverly Hills or Miami's southbeach or Midtown Manhattan, etc.

Private practices, esp really competitive ones and those in competitive areas are looking for people who will help build the practice, not who they have to help along forever. In other words, there are those personalities and skills that sell themselves and there are those that don't. Assuming that the applicant is not a total dufus w/ their surgical skills, it is so much better for a practice to hire someone who is marketable from the personality standpoint.

The practice which grows the fastest is the one where the patients love the doctor. Word spreads quickly. It's not common to hear patients say things like, "I know he's not easy to talk to and always seems hurried, but that doc is from Johns Hopkins. That's enough for me."
 

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[My financial guy's] point was that with inflation steadily climbing over time, low-interest loans actually become almost no-interest in 10-20 years. Better to invest the money that you would use to try to pay them off early.

You should be careful with this line of thinking. If the loan is gone, you don't have to pay it. Regardless of inflation, you still will have to send in the check each month whether you have the money or not.

That type of talk is typical financial guy talk. They like to leverage debt, etc. Instead I strongly recommend you strive to be debt free as much as possible. I know my suggestion is unsophisticated and unoriginal but trust me, it's the best way to avoid insomnia.
 

TheThroat

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I'd like to hear from TheThroat on this one since he went to one of those top tier programs, but my impression is that it doesn't for private practice for the most part. I think it might if you're dealing with an uber-competitive group in a ridiculous location like Beverly Hills or Miami's southbeach or Midtown Manhattan, etc.

Private practices, esp really competitive ones and those in competitive areas are looking for people who will help build the practice, not who they have to help along forever. In other words, there are those personalities and skills that sell themselves and there are those that don't. Assuming that the applicant is not a total dufus w/ their surgical skills, it is so much better for a practice to hire someone who is marketable from the personality standpoint.

The practice which grows the fastest is the one where the patients love the doctor. Word spreads quickly. It's not common to hear patients say things like, "I know he's not easy to talk to and always seems hurried, but that doc is from Johns Hopkins. That's enough for me."

In private practice, where you went in residency means almost nothing. Getting a job may have a little to do with where you went in residency, but not much. Once you have a job, success in PP has to do with three things: affability, availability, and ability. Going to a high-profile school has absolutely nothing to do with the first two and only marginally effects the third.

Beyond that, probably more patients would be impressed by "big name" schools like Harvard, Yale, and Duke would probably mean much more to patients that programs like Michigan, WashU, or Iowa.

Thus, it shouldn't be surprising that most patients are not impressed at all by my going to Iowa.
 

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You should be careful with this line of thinking. If the loan is gone, you don't have to pay it. Regardless of inflation, you still will have to send in the check each month whether you have the money or not.

That type of talk is typical financial guy talk. They like to leverage debt, etc. Instead I strongly recommend you strive to be debt free as much as possible. I know my suggestion is unsophisticated and unoriginal but trust me, it's the best way to avoid insomnia.

It is a good point that one has to assume that he will be working for 20 years to pay off a 20 year loan. If something were to happen and your career was to be cut short, you still have the debt.

That said, if you invest and you have enough to pay off the debts, then the debts are pretty much covered. (unless, of course, your investments all bomb).

Anyway, its a game of chance. Pay off your debts early and you don't have the debt. But, then again, you could pay off your debts over the years with 3-4% interest and take the money that could be used to pay them off and invest with something that brings in around 8-10 %. Can be a sizable chunk of change. Again, just depends on how you want to play the game.
 

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But, then again, you could pay off your debts over the years with 3-4% interest and take the money that could be used to pay them off and invest with something that brings in around 8-10 %. Can be a sizable chunk of change. Again, just depends on how you want to play the game.

THat means that you are netting 4-7% ( 3-4 subtracted from 8-10)before taxes. Since inflation traditionally hangs at 2-4% that means you are making 0-5% over inflation before taxes.

Doesn't seem like much when you consider the risk, does it?
 
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TheThroat

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THat means that you are netting 4-7% ( 3-4 subtracted from 8-10)before taxes. Since inflation traditionally hangs at 2-4% that means you are making 0-5% over inflation before taxes.

Doesn't seem like much when you consider the risk, does it?

Richard Boureston
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We can go around and around about risk vs reward as far as the financial aspects of paying off debts early vs late. I am not telling anyone a professional opinion, just what I have been told from financial advisor that I trust.

Obviously, you are a proponent of paying off debts early, and have made good arguements for doing so. With that in mind, there are obviously others who believe that paying off debts over time is a wiser move. I provided a rudimentary arguement for paying off debts over time, but it really is fairly basic with little more than guesswork on my part. The fact is that I have little true financial acumen, and, like most docs in my position, sought the experience of financial advisors who I trusted.

What I would advise to anyone with debt is to seek sound advice, not just what a few dudes recommend on an internet forum.
 

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We can go around and around about risk vs reward as far as the financial aspects of paying off debts early vs late. I am not telling anyone a professional opinion, just what I have been told from financial advisor that I trust.

. . .

What I would advise to anyone with debt is to seek sound advice, not just what a few dudes recommend on an internet forum.

I enjoyed your earlier comments because they are what most people receive from their financial advisors. I too am not interested to "go around and around" but instead I want to present an alternative viewpoint.
 

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Any of you guys in practice or close to practice want to comment on the job market these days and possibly in the future? How easily are ENT's finding reasonable jobs where they want these days? Compared to other surgical specialties?

edit: nevermind i believe i found some information on it in another thread further down
 
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