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Salary considerations for Otolaryngology

Discussion in 'Otolaryngology' started by otoforce1989, Jan 17, 2018.

  1. otoforce1989

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    Hi all,

    I'll start by saying that yes, I fully realize and agree that choosing a path in medicine should not be a purely or primarily income-driven decision. Please no replies saying that if this is what's important to me I shouldn't be a physician at all, etc. etc. Thanks :)

    That said, as I'm rounding out 3rd year of ENT residency and thinking about what specialty to choose, I'm having a ton of trouble finding any reliable information on earning potential for the various sub-fields and for academic hospital vs. private practice settings.

    Just for my information and to keep in the back of my mind, I'd SO appreciate it if anyone could provide data points on income trajectory for Facial Plastics, Rhinology, and Neurotology (these are the 3 I'm considering). I'm planning to do a fellowship, get my start as an attending at an academic medical center, and later transition to private practice.

    Also I'll likely reside in either Boston or NYC (or surrounding areas like Westchester County), since I know that geography does have an impact here.

    Any data points, insight, or context you could provide would be very much appreciated! Thank you!!
     
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  3. OtoHNS

    OtoHNS ENT Attending
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    Unfortunately, I don't know a whole lot about starting salaries in the Northeast (I practice quite far away from there).

    I'm in private practice so my viewpoint is mostly from the aspect of a business owner, not an employee. But the same general ideas can be applied to either an employed physician or an academic physician, where there are typically income incentives based on your RVU production.

    I would think about your income potential in terms of what types of patients you'll be seeing and what types of procedures you'll be doing.

    Rhinologists will obviously be seeing a lot of sinus patients. As a result, you'll be doing a lot of nasal endoscopies and endoscopic debridements in the office. By doing a nasal endoscopy, you transform a $50 follow-up visit into a $250-300 follow-up visit. Likewise, you transform a $100-150 new patient visit into a $350-400 visit (or $500+ with CT in the office). Obviously, this should not be abused (i.e. don't scope your earwax patient), but as a rhinologist, a very large portion of your patient volume will need nasal endoscopies or debridements for adequate evaluation and management. At volume, this adds up to a lot of revenue very quickly.

    Depending on your practice setting, you may also be doing a lot of in-office balloons, which also pay very well. Counterintuitively, you might actually not do that many balloons if you are the sinus expert in a large ENT practice (your partners will snatch them up and send you the revision frontal sinus case) or in academia (the private practice guys will snatch them up).

    Finally, there are natural ancillary sources of income for rhinologists like in-office CT (pays ok) or allergy testing/immunotherapy (can pay very well at volume).

    So, in my opinion, most of the time, the rhinologist will win in terms of income among your 3 options.

    The exception would be if you could develop a busy, all-cosmetics facial plastics practice in Manhattan or a wealthy suburb. This is obviously a cutthroat setting and takes a certain personality, grit, and ability for self-promotion that not many have.

    Many facial plastics ENTs are doing a lot of reconstructive work or general ENT, which obviously does not pay as well as facelifts and cosmetic rhinoplasties. If you're in academia doing a lot of trauma and free flaps, you'll definitely not be earning tons of RVUs (though this work can be rewarding for other reasons).

    Otologists will probably do reasonably well, but somewhere in between.

    Hope this is helpful.
     
    #2 OtoHNS, Jan 18, 2018
    Last edited: Jan 18, 2018
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  4. otoforce1989

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    @OtoHNS that's extremely helpful, thank you!

    Something else I'm interested in (pretty far into my future, I'll admit) is building out an Integrated Practice Unit (IPU). I have bit more research to do on this front but just from personal experience is this something you see much of in ENT, and are there any IPUs in which you think a rhinologist could play a key role?
     
  5. OtoHNS

    OtoHNS ENT Attending
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    I will admit I'd never heard of the term IPU until your post. Perhaps there could be one for chronic sinusitis patients, but it's not something I've ever heard of. Would probably work best in an academic setting or if you worked for a large organization (i.e. Kaiser or the like).
     
  6. neutropeniaboy

    neutropeniaboy Blasted ENT Attending
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    I'll tell you what things are like from an academic standpoint.

    Academic institutions have different missions and pay their physicians quite differently, and the reasons why one might choose another will of course vary heavily, possibly regionally.

    Scenario 1: Academic institution pays a flat (or graduated) salary. There is no incentive for production; there is no real penalty for under-producing. These salaries in ENT are generally below average in terms of not only the academic markets but also the private practice markets. The advantage of such a set up is that there is (generally) less pressure to churn out patients, do procedures and more of an incentive to actually think about the patient, spend more time with the patient and -- take this with a grain of salt -- practice evidence-based medicine. If there is a financial incentive to perform surgery and the evidence is 50-50, if you're paid for additional surgery, most people are going to do the surgery. If there's no incentive, one might be inclined to medically manage. The drawback is that there may be little growth opportunity from a financial perspective if you tend to be on a productive side. This usually results in three dichotomous pathways. On the first road, the physician eventually realizes that he is being underpaid relative to the money he is bringing in, feels as though the institution is taking advantage of him and moves on. On the second road, the physician is content to work 9 to 5 and go home. On the third road, the physician eventually says "why do I bother?" and stops being productive, sees 5 patients per day, and spends the rest of the day doing "research" or pontificating.

    Scenario 2: Academic institution pays base salary and incentives based on cash collection. The base salary for hospital employment may be something ridiculously low (like $100,000/y) and the physician may also receive a university salary, also ridiculously low. However, the physician takes home a percentage of the monies he brings into the institution. The percentage may be fixed or it may be negotiable. This pay model is obviously HEAVILY dependent upon the market and the payor mix. If you've got all Medicaid patients, you ain't making much. But if you've got 5x Medicare Blues, then you're rolling in income. Salary will fluctuate from year to year and it will always be based on market, payor mix and productivity. Can be comparable to PP models. Some academic institutions can corner the market and demand higher payouts from insurance providers.

    Scenario 3: Academic institution pays base salary and incentives based on wRVU productivity. This is my practice model. The base salary is usually higher than in Scenario 2, and often regional benchmarks are used to set the expected wRVU productivity at the 50the percentile (or other). Once a certain number of wRVUs has been exceeded, the bonuses kick in. The dollar per wRVU may be different for each type of division. The head and neck surgeons may have a higher dollar per RVU because they admit patients, order a lot of imaging, consult med/rad onc, require a lot of resources, etc. The dollar per wRVU for rhinology is usually pretty good because of scopes and CTs and use of disposables. The dollar per wRVU for laryngology and otology tend to be lower. On the other hand, the $/wRVU may be fixed for all divisions within ENT. The obvious advantage with this scenario is that it doesn't matter what insurance your patient has; you get paid based on wRVUs, which are set by Medicare. Another obvious advantage is that the more you do, the more you collect. The drawbacks of this system are frankly more than the advantages. Work RVU "values" are only going DOWN over time. Therefore, if all else was equal, you can expect to earn less over time if you're seeing the same number of patients and doing the same number/mix of surgeries. Another not-so-obvious disadvantage is that if you're in academics, a lot of the times, the surgeries are a lot harder (they're revisions or difficult cases to begin with). Guess what? an RVU is an RVU, regardless if the procedure takes 20 minutes or 3 hours. This may -- surprisingly -- make people NOT want to do surgery. If you can see X number of patients in clinic and earn more wRVUs than it you would earn doing surgery over the same interval, why would you ever operate (if you're goal is wRVUs)? This system can also be heavily abused. Patients who don't need surgery might end up getting it from unscrupulous docs -- especially if the risk is extremely low. Can be comparable to PP models, but generally less than a productive PP ENT makes.

    Scenario 4: a mix of 2 & 3.

    Many academic departments will also dish out bonuses based on how much they are in the black at the end of the year. A source of consternation is that often departments are in the black because of a few providers, and the way bonuses are handed out isn't always equitable (less productive people getting the same or more than the productive people). Often a university will claim that their contribution to the salary (the hospital, which is often a separate entity from the university is usually much higher) is for all the academic work you do -- research, lecturing, etc. Some people who are overly academic -- lots of research, lecturing on the circuit, national leaders, etc. -- have a legitimate gripe that this takes away from their clinical time without recognition or other pay to compensate. They argue "why be academic" if they're not paid to be academic in an academic institution. Reasonable grip.

    I most cases, during the first few years of employment, most new physicians are given a guaranteed salary -- possibly with some bonus features. You may join the incentive plan sooner if you're atypically productive if your system does have an incentive plan.

    Of course, there are often people who get paid at individualized rates, etc. because of prestige or because they bring in an unusually large amount of money. Even in academics you have the potential to earn quite a bit. You just have to decide what your personality is and what scenarios are going to work for you.
     
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  7. dasnot

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    ENT resident here. Right now considering whether to do a fellowship, mainly neurotology or facial plastics, or just do general ENT. Want to go into a group practice in small city/ rural town in the Mid-West/South.

    Was wondering if anybody currently in practice can comment on what the future/demand for neurologists vs plastics vs General ENT might look like and what an expected compensation might be for these fields.
     
  8. OtoHNS

    OtoHNS ENT Attending
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    In rural areas and small towns, there is a HUGE demand for ENTs. I get several unsolicited emails a week from headhunters advertising a list of 30+ available jobs, most of which are in smaller cities.

    If you want to go to a smaller town to work, you should be able to get your pick of jobs without any problem, especially if you are not limited to a small geographic area. And since the group you'll join is probably the only show in town, you'll be busy (and earning $$$) very quickly.

    I would not recommend that you do a fellowship. In a small town, patients need a good general ENT who can take care of a wide variety of issues.

    Just because you are out of residency does not mean that you stop learning. I would pick your job wisely and look for experienced senior partners who are willing to teach and assist you on cases where you are not fully comfortable. A busy general ENT in a small town with 10+ years experience will have seen and done it all and you may be surprised to find out that they are better surgeons than most or all of your attendings right now.
     
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  9. dasnot

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    @OtoHNS

    Thanks for the reply. One of the reasons I would like to go back to smaller town is having the ability to treat a broader range of conditions. Your remark about the senior partners was a really good point; one that I had not really considered previously.

    Any ideas/ball-mark estimates on the earning potential in this situation?
     
  10. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor
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  11. OtoHNS

    OtoHNS ENT Attending
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    Depends on a few factors:
    1. Employed by a hospital/health system vs. Owner/Partner of your practice. In the long run you will probably make a lot more as a partner/business owner because you keep 100% of your profits. You also have much more control over your life. The downside is you have much more responsibility than just being an employee.
    2. Your Payer Mix- What is the percentage of patients with good private insurance (low/no deductible, PPO), crappy private insurance (high deductible, HMO), Medicare, Medicaid, Obamacare. Obviously, if most/all of your patients have good private insurance, you will earn more (or earn the same seeing less patients).
    3. How hard you want to work/how many patients you want to see in a day
    4. What kinds of conditions you focus on. If you like to do a lot of sinus, you'll probably make more. If you are able to establish some cosmetic stuff in your practice, you will make more (depends on your town's demographics and your competition how easy this will be).
    5. Any ancillary services: hearing aids, allergy, aesthetician, etc
    6. Passive income from ownership in an ASC or practice-owned real estate.

    After a couple years establishing yourself, I think $500K+ is quite doable, and $1M+ is possible if you work hard and are aggressive at identifying and scheduling patients that will benefit from high-paying treatments.
     
    #10 OtoHNS, Apr 13, 2018
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  12. dasnot

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    @OtoHNS @Pir8DeacDoc

    Thanks for the comments.

    One of the reasons I am considering pursuing a fellowship is to prolong my time that I would have lower payments for PSLF. I graduated with about 190k in student loans and upon finishing residency, I will have 5 years of qualifying payments. If I were to do a fellowship, that would be another 1-2 years that I could have that count towards PSLF... But looking at fellowship programs, I have a strong suspicion that some of the programs are not 501(c)3 programs and thus the fellowship years would not count - and PSLF would be a lost cause. Also, as good as PSLF sounds to have loans forgiven, I am a little skeptical that it will really work out.

    So that is one of the reason I am contemplating pursuing a fellowship. I am trying to figure out if it the best way to attack my loans, either just paying them off myself or going for PSLF. Any suggestions on what you all would do?
     
  13. DoctwoB

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    Fellowship for pslf doesn’t make sense. First the difference in salary of say 300k vs 60k (take home 200 vs ~50) will more then pay for the loans in 1-2 years. Second pslf loan forgiveness is taxable, meaning for 190 forgiven you would owe ~60k. Third being an attending doesn’t mean you can’t work for a 501c3
     
  14. DrBodacious

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    I am 5 yrs out of residency in private practice. Looking at some survey data I have from 2014, yearly salary # were:
    25th percentile is $310278
    50th percentile is $382705
    75th percentile is $471470
    90th percentile is $596337

    I really dislike the idea doctors have of expecting a certain compensation, though. There are a lot of factors involved, such that the above numbers are not very meaningful. Ultimately you should get paid for the amount of work you do, taking in to account how efficiently you do it.

    Reimbursement for various services and procedures tends to fluctuate, with a general downward trend in payments per service. Volume trends upward.

    The 75th percentile for revenue (collections) per year for an otolaryngologist is around $1,100,000. Your volume, payor mix and factors like how agressively you code and pursue payments can affect that. If people abuse procedures or over code, thing can go up 50% or more pretty quickly. These issues are not unique to otolaryngology.

    Given a certain amount of collections, your overhead is what determines your profit. There can be large variability in how many staff you use, how nice your office is, how nice your equipment is, how much you use profits for tax deferrend retirement savings or real estate investments that can reduce your salary but build wealth.

    If you are employed, expect to be subsidizing someone else. Hospitals tend to load up you clinic schedule and try to be stingy with staff and equipment. You may make 75th percentile, but they will try to work you to the bone so they know they ar making $. Academics usually make a little less, but they arn't churning out as much volume, typically, and typically have very nice/expensive equipment.

    I prefer to be in control of everything: overhead, employees, hours. I started solo, now am a partner in group of 5. I don't want to have to petition a board to use a scribe, get a new scope, fire someone, etc. I can do those things at will. And I sleep well knowing I get paid what I earned, not making money for someone else, or taking money I didn't earn.

    The conventional wisdom unfortunately seems to be that PP is dying. I would say that is foolish, it is really not hard to do.

    Frankly, it would make more sense to me to mandate that practices be physician owned. This is the case for attorneys, to make sure the law practice owners are held to the ethical standards that the legal professional body regulations require. This would solve a lot more problems than the ACA did.
     
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  15. OtoHNS

    OtoHNS ENT Attending
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    I agree with almost all of what Dr. Bodacious is saying. Private practice is certainly not dying, but depending on the setting it can be a lot more challenging. In a big city with lots of competition including big health system/hospital-employed ENTs, it is more difficult but still quite possible to succeed (my practice is living proof). In a smaller town where you are the only practice within 50+ miles, it is probably a lot easier.

    Graduating ENT residents have been jumping through hoops and getting told what to do for over 25 years of school and training. No one teaches you how to run a business and design your life on your own terms (this is because none of your attendings are doing it either). It's no surprise that most graduates want to just keep getting told what to do and where to go as an employed physician

    In my opinion, it is well worth getting out of your comfort zone to learn the ins and outs of running a practice. The payoff is much more control over your work/life, and most likely more income in the end.

    My advice to the OP- go start making money. You can pay off your whole debt in 1-2 years if you want.
     
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  16. dasnot

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    In my program, we do not rotate with PP so how does one learn the ins and outs of running a practice during residency if we don't get that exposure? Or is that something you just pick up once in practice with a group and learn from current partners?
     
  17. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor
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    Unfortunately for a lot of us it's the second.
    And let me forewarn you there are a lot of people that want to prey on your nievete. You can make a practice a lot of money. They may or may not trickle that down to you. Some see it as the new guy paying his dues. But keep your eyes open and don't let people get rich off your efforts.
     
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  18. OtoHNS

    OtoHNS ENT Attending
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    This is all true, but don't make the assumption that your partners are great businessmen/women. Ultimately, you have to educate yourself in these matters, and that education can start today if you want. Start paying attention to E+M coding and CPT coding while you're in clinic. You'll have to do this for every patient you see in practice. Learn the basics of how health insurance works (deductible vs. coinsurance, etc). Learn the basics of the wonderful ways the government is "helping" us to be better doctors (MIPS, etc). Your best bet is probably going on Amazon and finding a few books on basic practice management (ideally written by physicians, not administrator types).

    I'd also recommend learning about business principles in general: management of employees, creating systems/processes, marketing, etc. I wish I could point you to only one or two great sources, but I can't. You just have to dive in and start learning.
     
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  19. dasnot

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    When you are going over a contract with a private practice group, is it acceptable to ask the members about their contracts (i.e what their benefits, how they were paid, at what rate etc?) -- and use their contracts as a reference to make sure that you are not being taken advantage?

    When starting with a new group, how do you know that the more senior partners are not withholding some of your earnings, without directly confronting them?

    Are books enough to learn the principle of PP or would getting an MBA be something that would be actually beneficial?
     
  20. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor
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    Terrific Advice.
     
  21. OtoHNS

    OtoHNS ENT Attending
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    I don't want to assume, but it sounds like you don't have much practical knowledge about the difference between an employee and a business owner. This is ok, because I didn't when I was a resident either.

    Most people are employees, and this includes you right now, all your attendings in academia, and any physician who works for a hospital or health system. They get a regular salary, possibly with bonuses.

    Physicians in private practice are different because they own their business. However, unless you are the founder of a practice, you will start out by getting hired as an employee of the practice. To my knowledge, it is standard that you are employed for 2 years and then will have the option of becoming one of the co-owners of the practice (assuming you are doing well and everyone likes each other). This 2 year length of employment is negotiable and can be as short as 6 months to a year if you are busy enough to support yourself after that time. While you are an employee, you'll get paid a salary and probably some type of bonus based on your collections. You will almost certainly not take home every cent that you earn (and this is to be expected- there is no job in the world where you take home 100% of what you earn the company, unless you own the company). There is a good chance that if your practice has hired other docs in the past, your initial employment contract will be identical to the last physician(s) hired. It is not unreasonable to ask about this.

    The process of becoming a partner/owner involves legal paperwork and you will probably want a lawyer to review it for you. There will probably be a "buy-in" amount that you will need to pay to become a partner- this is negotiable and can vary widely based on your particular practice setting. If there is a standard buy-in, the practice will probably tell you this before you ever get hired. You should definitely understand the process of how you would become a partner before accepting any job.

    Once you are a partner, your pay will be partly a regular salary you pay yourself (same as any other employee) and partly distributions from the company based on your share of the profits. These distributions are typically given out quarterly, and have favorable tax status compared to your W-2 salary. In addition, there are many ways to save on your taxes as a business owner vs. an employee. This is a good thing, as it encourages people to own businesses and create jobs for others.

    I'd suggest learning some basics about business entities- corporations (C-corp vs S-corp), LLCs, LPs, etc. Get an idea of why corporations/partnerships exist and how they benefit you as a business owner. Most medical practices are LLCs, but this may vary depending on what state you live in.

    I would not recommend getting a MBA- this is not that complicated and you would spend a ton of money and time learning mostly irrelevant stuff in business school.
     
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  22. koojo

    koojo Don't Stop Believing
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    I signed a hospital contract in the middle of my PGY4 year, for the Northeast region. $425k guarantee. On top of that they offered a very genrous loan repayment, CME reimbursement, 30 days off a year, pension plan, 403b, health/dental/vision insurance, etc. They calculate that based on that years median wRVU payout and the expected production of wRVU. I get emails all the time for job openings across the country for guarantee salaries north of 500k...
     
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  23. Pir8DeacDoc

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    The details aren't in the guarantee stage of things. The rub is what you'll make after the guarantee is gone. I've always done PP but have heard stories of friends having their pay cut way down once their guarantee is over. Just something to consider
     
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  24. koojo

    koojo Don't Stop Believing
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    You only get burned if they're calcuting the guarantee based on an unrealistic projected amount of annual wRVU. You should know roughly what you'll be doing monthly. If they're basing the guarantee on a projection of 10000 annual wRVU's, and your guarantee is $400k a year...we'll thats a terrible salary, since it means your only making $40 per wRVU, whereas the average now is hovering around $60. That $40 per wRVU will really hurt you when you're off the guarantee and only doing 6000 annual RVU's.

    It's also important to negotiate being paid adequately for both sides in bilateral procedures, and be able to renegotiate your wRVU compensation based in the new annual MGMA data. Takes just a little bit of time to do research, but pays pays off big time in the end.
     
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  25. Pir8DeacDoc

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    Good info
     
  26. ENTGooner1982`

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    Hi all. I'm a PP general ENT on the West Coast. Not in a crazy high saturation area, but adjacent to several. Approaching 2 years out of residency. Just wanting to get a feel for how my experience matches up to other true PP ENTs.

    I joined a group with one sole owner and 3 other employees/providers (which I am the 4th). 3 offices. Basic contract structure is all providers take home 50% of collections-- so I bill for all my procedures, allergy testing, CT scans, but not hearing aids. Any supplemental call stipend $, which is optional for the various hospitals we cover, goes straight to us. Malpractice is covered. No other percs/benefits. No partnership track. No surgery center owned by us, though there are several in my area that I am considering investing in, but not anytime soon. I was hired to "open" a new office in an area previously unrepresented by our group. First year or so did a ton a marketing, going literally door to door to PCPs, building up referral base. I'm just now starting to be busy, but still feel there is tons of room for improvement in patient/surgical volume and collections.

    Have several questions. What does a typical clinical day/week look like for you? How many patients/new patients a day/week or month? What is overhead? How many front office employee's/MA's per provider? How many clinic vs OR days? In house billing vs. outsourcing to a company (we use MediGain for example)? Any other pearls from peoples early experiences, especially people who established clinics in new areas would be very welcome.

    I basically wrestling with the notion that I'm getting screwed by my situation vs. trying to be patient and continuing to ride the wave of slow growth. Wondering if/when/how I can renegotiate at some point and what leverage I have. Thanks in advance.
     
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  27. dasnot

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    @OtoHNS @ENTGooner1982` @koojo

    Really considering Otoneurology... I know money isn't the only thing to consider, but I am trying to calculate lost income while pursuing fellowship... And rough estimations of Oto salary?
     
  28. Skeet1893

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    It was mentioned earlier that PSLF creates a taxable event. This is not true.

    While other forms of forgiveness or loan repayment are generally considered income; PSLF is not.
     
  29. DrMdSoon

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    Realistically, what can I expect to make in NYC coming out of a facial plastics fellowship?
     
  30. turboE36

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    Are there any ENTs near the 1M mark in salary? What does it take to achieve this?
     
  31. OtoHNS

    OtoHNS ENT Attending
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    Currently, I'd say most (all?) of the ENTs making $1M+ per year are:

    1. Doing a high volume of high-reimbursing procedures. Right now, these would include in-office balloon sinus dilation and cosmetic surgeries
    2. Making money from passive income sources (hearing aid sales, allergy, surgery center, practice-owned real estate, etc)
    3. Owners or partial owners of their practice
    4. Business savvy- meaning they understand and control how their business works, understand how to market and advertise their business, and continually work to optimize these systems.
     

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