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salary taboo vs reality
- Thread starter nurofiber
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35-40 patients a day is hardly overworked. That should not be too taxing with decent tech support and an efficient EMR. Many fellowships follow ACGME payment guidelines which would not be "living like a pauper". Starting salary is just a starting salary. If you are reasonably busy with a normal overhead and a normal bonus structure you should be living quite comfortably, even before partnership. Starting at 180,000 to me however is not underpaid. I also work in a very saturated and busy metropolitan area and live comfortably with a family without concerns of bankruptcy despite my 250k student loans. I enjoy what I do. Work 5 days a week clini and OR and take occasional call. I do have a much higher ceiling with partnership but I'm doing fine as is as well.
I doubt this helps because we have fundamental differences in perception of what is busy and what is underpaid. What field are you looking to switch into? Best of luck in whatever you decide!
I doubt this helps because we have fundamental differences in perception of what is busy and what is underpaid. What field are you looking to switch into? Best of luck in whatever you decide!
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The lack of discussion about this is problematic, and doesn't parallel the culture in other specialities, where I think earning potential is much more openly discussed. It's far from taboo, it's a critical component of our lives and definitely plays into our career decisions daily, and I wouldn't believe 95% of individuals who would say it doesn't. It is important, we have had a huge financial and time opportunity cost. We have loans, families to support, etc. And we want to live more or less nice lives, which I don't feel so guilty about with all that I have put in and sacrificed. All that being said, salary is of course not the defining factor of why we chose ophtho, and this should be inherently assumed without need for constant clarification or reiteration. Most on this board are beyond having decided ophtho is the right choice for a myriad of reasons, and now it is onto having legitimate questions: what now, what can I anticipate, and how do I position myself in the best way. I'm just a resident, so I can't give my 2 cents, but it would be very nice if some of the practicing doc's on here shared more about salary detail and the specifics of how to get into a successful practice, what true earning potential is (sub-specialties in mind, rural vs. metropolitan being known factors of discrepancy and what the discrepancies actually are), what to look out for in joining practices, etc. The down and dirty details right down to speciality specific RVUs are very much discussed on other specialty boards with important career specific advice.
4424 - what kind of salary increase do you anticipate over the next few years? what is a realistic career goal? are you sub-specialized?
I think all of medicine just assumes that ophtho is filthy rich, when I tell my colleagues that ophtho start is about 150-200K I literally get jaw-dropping reactions, and "wow, IM and hospitalist's make more!" -- which is true, and it burns a bit to hear that over and over again without even having a clear understanding of how my start salary will compare with my career long salary. I get that 180K is still a great life salary, but 4 years of med school, hundred's of thousands of debt later, and 4 years of residency later - it doesn't seem enough when your fellow IM doc or hospitalist is starting at 250K with a great lifestyle, and probably did not even have to fight to match. You look at derm, rads, IM, EM, really anything and you can easily start at 250K with 300-400K career earning potential with life-style preserved, and I am wondering if this is realistic in ophtho. It's entirely possible that the lack of discussion here just makes this board unfavorably skewed and disillusioned, but I think this discussion should be promoted and thorough, because otherwise the lack of it is just making the grim outlook appear to be the reality.
4424 - what kind of salary increase do you anticipate over the next few years? what is a realistic career goal? are you sub-specialized?
I think all of medicine just assumes that ophtho is filthy rich, when I tell my colleagues that ophtho start is about 150-200K I literally get jaw-dropping reactions, and "wow, IM and hospitalist's make more!" -- which is true, and it burns a bit to hear that over and over again without even having a clear understanding of how my start salary will compare with my career long salary. I get that 180K is still a great life salary, but 4 years of med school, hundred's of thousands of debt later, and 4 years of residency later - it doesn't seem enough when your fellow IM doc or hospitalist is starting at 250K with a great lifestyle, and probably did not even have to fight to match. You look at derm, rads, IM, EM, really anything and you can easily start at 250K with 300-400K career earning potential with life-style preserved, and I am wondering if this is realistic in ophtho. It's entirely possible that the lack of discussion here just makes this board unfavorably skewed and disillusioned, but I think this discussion should be promoted and thorough, because otherwise the lack of it is just making the grim outlook appear to be the reality.
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It's pathetic to get primary care reimbursement rates? So, ophthalmologists are somehow better than primary care docs? It's not enough to just say that it's pathetic to get LOW reimbursement rates, but it's pathetic to get PRIMARY CARE reimbursements rates...?
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I really doubt that is what he meant to say here nor is it how I read it in even the least. Not sure why there is so much attitude in the post. No point in arguing here and I won't perpetuate the tension beyond this:
Very transparently I think what is meant here is that reimbursements should be different among two different specialties that entail completely different skill sets, procedures, training, and complication risks/stresses for a practicing physician. Whether it be primary care and ophthalmology, or any other 2 completely different specialities, you will come out with different compensation rates, as you should. This is not to diminish primary care reimbursement or the field itself, or undermine it's importance in medicine which is undoubtedly huge, or to say that anyone is better here, nor to say that primary care reimbursement or the speciality itself is pathetic.
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Neurofiber, what you are concerned about is very real. This has been real for a very long time and will not get better any time soon. Position offerings in competitive areas are miserable. Predatory practices churn associates every 2 years in LA, San Francisco, NY, etc. Good partnership opportunities are more of a myth unless you are coming into your daddy's practice or get incredibly lucky. Anesthesia, ortho, ENT, plastics although tough can still find something decent and leading somewhere. Neurosurgery, heme-onc, derm, primary care can write their own ticket ANYWHERE they go. Ex., good friend just signed primary care with So Cal Kaiser $290K start, where as general ophtho starts ~$220K and getting one of these positions is still impossible. Of course, you can move to a "small Southern town" as Lightbox will tell you and collect $$$ from your surgery center, optometrists, optical, etc. But this is not for everyone.
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Haha, okay first thing you have to do: review my previous posts on how great Ophthalmology is in terms of $$$ (if that is your thing). And no, I don't practice in some "small Southern town", but I'm sure that the eye surgeons that do are making a killing and aren't fighting over every cataract like some other docs out there.
Third, most people in my similar situation scoff at the difference between 220k vs. 290k. There really is NO significant difference in lifestyle between those starting salaries. Heck, even "300-400K career earning potential" is a bit of a joke. I think there is a definite change of lifestyle toward the 600-800k level, but it is all relative. Not to sound too elitist, but I can't imagine being down at 600k anymore. Yes, you get used to whatever level you achieve, and it is hard to go DOWN in compensation once you reach a certain level.
Again, most of the principal guys around here that OWN their practice make in the 7-digits for sure. And yes, they profit off the work of their associate Ophthalmologists, Optometrists, etc. That being said, do you really need 7-figures to be happy? The answer is a definite NO. If you can't be happy with 200-300k, you won't be content no matter how much $ you earn. I achieved my revenue level pretty quickly, so I'm still used to living like a fellow. I just stick my money in my brokerage account, because I don't need the newest Tesla or whatever to be happy. I would rather watch the # in my brokerage account grow and feel good that my family is financially secure.
One thing that we can all agree on is that you won't learn how to make this level of dough from your academic attendings and advisors. I love them all and owe my training to them, but you won't learn how to run a business from them. Lastly, to switch specialties solely because of posted associate salaries is just plain foolish. If you suck at the business of Ophthalmology, you are going to suck no matter what field you choose (sorry for the lack of eloquent vocabulary!).
Third, most people in my similar situation scoff at the difference between 220k vs. 290k. There really is NO significant difference in lifestyle between those starting salaries. Heck, even "300-400K career earning potential" is a bit of a joke. I think there is a definite change of lifestyle toward the 600-800k level, but it is all relative. Not to sound too elitist, but I can't imagine being down at 600k anymore. Yes, you get used to whatever level you achieve, and it is hard to go DOWN in compensation once you reach a certain level.
Again, most of the principal guys around here that OWN their practice make in the 7-digits for sure. And yes, they profit off the work of their associate Ophthalmologists, Optometrists, etc. That being said, do you really need 7-figures to be happy? The answer is a definite NO. If you can't be happy with 200-300k, you won't be content no matter how much $ you earn. I achieved my revenue level pretty quickly, so I'm still used to living like a fellow. I just stick my money in my brokerage account, because I don't need the newest Tesla or whatever to be happy. I would rather watch the # in my brokerage account grow and feel good that my family is financially secure.
One thing that we can all agree on is that you won't learn how to make this level of dough from your academic attendings and advisors. I love them all and owe my training to them, but you won't learn how to run a business from them. Lastly, to switch specialties solely because of posted associate salaries is just plain foolish. If you suck at the business of Ophthalmology, you are going to suck no matter what field you choose (sorry for the lack of eloquent vocabulary!).
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People are doing fine with regard to jobs upon graduation. There are more patients every year so the demand is there. Major metro areas are saturated with every type of specialist. You never know which specialty will be next in terms of reimbursement cuts or increases. Thus pick the specialty you can get up every morning and look forward to doing.
Nurofiber, in answer to your question, my future potential is 7 figures. Just as there are many good jobs out there, there are also many bad jobs out there, I agree. I can't compare if it is more or less than other specialties but I do agree with the rapid associate turnover in many practices. I did see that extensively when interviewing for jobs. However, it is possible to find good jobs in saturated, urban areas. I am sub specialized and I did not take over anyone's practice or have any family ties. I think it's easy to make generalizations and the discussion is important to future applicants. Where we differ though is the "love for the field aside". That is huge to me. I have friends who are ER docs who work half a month and take home a lot of money but it's not something I could do. If reimbursement continues to drop, it's possible I would not hit my expected ceiling, but I am fine with that. I think the interest and love for the specialty is essential, no matter what specialty you decide.
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Just a few things,
If you think seeing 35-40 pts a day is being overworked in ophthalmology, you're going to be in a rude awakening in other fields. Primary care providers in urban centers will double or even triple book on full days. In private practice, you won't be having many train wrecks like in residency, so if you can't manage that in a day, something is wrong with clinic flow or whoever is providing care is just plain inefficient.
I've been a long-time poster/lurker, and though salary issues aren't discussed as much here compared to other forums, it's definitely not taboo. There are many frank conversations about salary and cash/reimbursement flow, and the insight provided in these threads is pretty valuable.
Yes you may have to move to take a job, or work in, god forbid, a southern city, but that's true for many fields. The demand for providers in any field have an ebb and flow; one field that is crazy in demand may suddenly be saturated a few years later. If you're in a major metropolitan area, it's going to be competitive, but it'll be competitive for most fields. The good jobs for these metro areas may be advertised word-of-mouth, so often you'll have to network and maybe take some risks to find a job in a very desirable location. Even in bigger metro areas, if you're ok living 1-2 hours away, the demand goes up. In my state, I had to tell recruiters and head hunters that I wasn't doing general ophthalmology so they'd quit calling me every week.
On that note, this is where sucking in the "business of ophthalmology" matters. Positions that are open for quite some time are that way for a reason, which some graduating residents somehow don't quite grasp. There are lots of tell-tale signs of predatory groups, and just some simple investigation goes a long way. Finding the better jobs require networking, connections, and sometimes the help of your mentors in residency. Of course, some academic faculty aren't of any help in this regard, but it only takes one of them with a good recommendation and lead to get you a good setup. Yes, the starting salary may be lower than your peers, but this is not necessarily a bad thing. Some groups have a bonus structure where once you bring in a certain amount of revenue, you start keeping a portion of the revenue that you bring in. For instance, one of my colleagues was actually glad to have an average starting salary because he was able to hit that threshold and rake in his bonus. I don't remember the exact details, but the bonus structure worked out that if you brought in 2.5 x your salary, you got to keep 30% of any additional revenue to the practice. I know that other fields may give you a higher starting salary, but with a bonus structure like that, if you get your clinic ramped up, hitting that bonus revenue is very feasible.
Last, if you're looking for that magic ticket for a high salary with an easy lifestyle, you're in the wrong field. You can decide how much you earn, how you'll work, where you'll work, or when you'll work, but you can't choose them all. If you want it all, medicine is definitely not the field to be in, but there's no reason to belabor that point. It may seem that the grass is greener on the other side, but it's not. Your statement about nurses is not correct either; there's a perceived nursing "shortage," but only for areas where most nurses don't want to be.
FYI not all retina fellows are paid 40k; my fellow pay is 60k a year. It's not massively more, but it's definitely better.
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Your attitude is exactly why you will be a self-fulfilling prophesy. Too many new grads share your outlook: they think just because they graduated from Ophthalmology residency, that someone is going to hand them a 500k/year job by default. That's not how any business works (including Medicine), and if you cannot understand that, then good luck to you. Do you think that any practice owner is just going to hand you over tons of $$$ with that sort of attitude or want to be business partners with you? Hell no. And if you want to chastise these practice owners as being "predatory", then guess what -- you are free to start up your own practice!! No one is stopping you. You can't expect to make the dough AND somehow not take any financial risks. That's not how the world works. Any entrepreneur understands this, but sadly, most doctors do not.
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This is why I advise 20-some-year-olds to go get a job in the real world before starting med school. Learn about real life, real business. Work in the trenches, have a boss, meet deadlines, rise to the occasion, build your professional skill set. It will serve you very well in medicine.
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Interesting discussion.
No one is bashing you nuro, but what you may be realizing is that ophthalmology is a different subspecialty when practiced in the real world than say IM or Gen Surg.
If your goal is to be an employed physician at a hospital or big HMO, then ophthalmology may not be the right fit for you. It is rare to find a hospital employed ophthalmologist and if you asked most of us that are out in practice, we are GREATFUL that this is the case!
Now there are plenty of employed ophthalmologist in private practice but as has been mentioned before, there is both pros and cons to this set up.
Ultimately, you can make any practice set up work financially, and no one is saying you don't have the work ethic or business acumen to make it, but understand that private practice and the mindset of a doctor working in that setting are much different than a salaried physician.
No one is bashing you nuro, but what you may be realizing is that ophthalmology is a different subspecialty when practiced in the real world than say IM or Gen Surg.
If your goal is to be an employed physician at a hospital or big HMO, then ophthalmology may not be the right fit for you. It is rare to find a hospital employed ophthalmologist and if you asked most of us that are out in practice, we are GREATFUL that this is the case!
Now there are plenty of employed ophthalmologist in private practice but as has been mentioned before, there is both pros and cons to this set up.
Ultimately, you can make any practice set up work financially, and no one is saying you don't have the work ethic or business acumen to make it, but understand that private practice and the mindset of a doctor working in that setting are much different than a salaried physician.
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I totally get what you are saying, and I have felt the same about medicine in general when my friends were making more than I would as an attending straight out of college, but try to keep things in perspective if you can. My friends work in cubicles and have literally no interesting aspects if their work. Their work also doesn't benefit anyone but the com
I get what you are saying. I was p***** when I saw what my friends were making out of college (More than I will make as an attending). The reality is their jobs kinda suck. They sit in cubicles all day and work for a company that is only interested in making money. That's cool, but I would probably shoot myself if I were in a similar position. You can change someone's life with your work. Yeah, maybe they could have gotten their surgery from someone else, but they got it from you. Just try to feel that for a minute. That is so much better than some corporate bs. You can disagree as much as you want, but you get to do cool s*** at work, and it helps people live more completely. I get it. I do. But some families live on 5 dollars a day and are still happy. And in the end we are just space dust. Money isn't s*** when you are on your deathbed, and no one cares what school your kids went to. You can find a job somewhere with good schools for your kids that you can afford. That's all that should matter. Sorry if this sounds preachy/cliche, but sometimes I feel the same, and this is the talk I give myself to put things into perspective.
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Wrong.
You are a self-fulfilling prophecy. No amount or reasonable discussion will change your mind so please go ahead and switch to whatever field you think is immune to the realities of medicine. You seem to think that working for a hospital will solve all your problems, and boy will you be in for a rude awakening.
Did you start this thread to discuss salaries in Ophthalmology (not taboo) or just to find anyone else willing to commiserate with you and your pessimistic outlook? There is reasonable advice and information here, you just refuse to accept it.
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Kaiser (on the east coast) starts general ophtho new grad at $273,000. Seeing as they are at all of the career fairs and are recruiting heavily I don't think it's that hard to land one of those spots.
OP, where are you looking to practice? Major city like DC or NYC? Suburbs? Rural? If starting salary is very important to you don't go for private practice. Hospital-employment will yield you a higher starting salary but will have a lower ceiling than private practice.
Yeah, I'm not really sure why that entire thread was deleted. I'll summarize some of the main points ;-)
- Practice buy-ins vary ALOT. I really don't think there is any "set formula" by which an associate will buy into a practice. I believe that a practice buy-in will be more expensive if the owners are younger, since they have less incentive to give up equity. For example, if a practice is owned by one person and has a net profit of 1 million, then why would this young owner give up 50% of the equity for a measly 1 million? It does not make much sense in this situation since the owner could easily earn that 1M back in 1 year and still retain 100% of the equity. The situation is different if the owner is old and wants to retire soon. In that case, getting a 1M check makes more sense since the owner does not want to work much longer. For a young owner to give up any equity, he is hoping that the OVERALL profit will increase by having the extra provider want to stick around since he/she now has an equity stake. That is the reason an owner wants the associate to work for him for a few years... to see if: (a) the overall profit will increase enough such that the original owner's take-home increases overall if he lets this guy buy in; and (b) he can actually get-along with this new associate. It is one thing to have a pain-in-the-ass associate, but a much worse thing to have a pain-in-the-ass business partner that you can't get rid of anymore! Let's say that the owner decides having this associate as a business partner makes sense. Then the owner is probably going to offer the max buy-in price that he can get without scaring off the associate. Conversely, the associate is going to only pay the minimum buy-in price without scaring off the owner from withdrawing his offer. Thus, there likely will be negotiation somewhere in the middle. Both the owner and the associate will likely get formal practice valuations from consultants and come to a negotiated price somewhere in the middle. The period of the buy-in also widely varies. Some owners will accept a full buy-in immediately, but sometimes the associate won't be able to secure a bank loan or afford its required payments. Other owners will only allow the associate to buy in a certain % per year (e.g. 10% per year for 5 years). There is no hard-and-fast rule to these things.
- "Average salary" of partners. Equity owners do not think in terms of salaries. Salaries are the pittance that owners pay themselves to fulfill IRS requirements for corporations. At my practice, us owners pay ourselves a salary of 250k/year. What we think of as owners is what our monthly "distributions" are going to be (i.e. the net monthly profit of the business divided among owners according to their equity stake). My monthly distribution is in the low 6-figure range. Obviously, these monthly distributions are going to be directly dependent on how profitable the business is during that month. The absolute/net profit varies widely but, as reiterated countless times, these are some of the main factors:
* # of owners (e.g. more owners == more division of the profit)
* # of non-owner providers (e.g. more associates/optometrists/PAs, etc --> more revenue hopefully generated without having to pay them any distributions)
* insurance mix
* ASC ownership (e.g. ~1/3 of my distribution is from the ASC facility fees)
* cash services
* # of optical shops and other ancillary product/service income streams.
* real estate ownership / rental income
* how efficiently your clinic and ASC are run (i.e. overhead). The biggest overhead for most businesses is STAFF (salary, benefits). Some practices have very low overhead, but also very low revenue because they cannot see patients with low staff.
Conversely, some practices have very high overhead, but also very high revenue because they churn them out. Obviously, having low revenue but high overhead is a bad combination!
I wrote more stuff, but those topics are escaping me right now. I'll try to remember what else I wrote later!
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From the point of view of a young associate, the next question then is what happens if you turn out to be in one of the many practices that churns through associates and there's no realistic possibility of partnership?
Other than start-up costs, the greatest obstacle to starting your own practice is restricted covenants. It's may be wrong to open up shop next door and "take" patients from a practice but it's not right working for a practice that holds out hope for partnership without ever really intending to follow through either.
Other than start-up costs, the greatest obstacle to starting your own practice is restricted covenants. It's may be wrong to open up shop next door and "take" patients from a practice but it's not right working for a practice that holds out hope for partnership without ever really intending to follow through either.
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All good points lightbox. A few things to add.
Other incentives to hire new associates and future partners: 1. larger practices with more offices cover larger geographic areas, thus there is a need for more associates/partners. If you are planning on growing the practice to have a bigger presence in the area you may need more help. 2. larger groups have more negotiating power with insurance companies. Small solo practices usually have less to offer and thus have less negotiating power. 3. To hire a quality associate, you will likely have to offer partnership. Young associates that are well trained, are quality physicians and have the interpersonal skills needed to flourish in private practice are surprisingly hard to find. It will be difficult to hire one of these excellent candidates without a clear track to partnership. Truth is, as an owner you should want the best working for you and with you as they represent YOU (the owner) both directly and indirectly and give you the best chance at achieving the goals lightbox mentioned.
These predatory practice are the worst, however, many of these restrictive covenants don't just "feel wrong," they are also legally binding. They can be broken but takes a lot of legal assistance to get around. Unfortunately, if you signed a contract with a restrictive covenant you may have to leave town and open up shop elsewhere. Perhaps others have experience with this issue and can chime in.
The options are pretty clear:
- Try to fight the non-compete. Some of my friends have successfully gotten out of their non-competes by legal wrangling. Cost a pretty penny in legal fees (e.g. 50k), but worth it in the long-run if you really want to stay in a specific geographic location. Sometimes you cannot eliminate a non-compete altogether, but can limit some of its scope.
- Open up shop just outside of your non-compete radius.
- Move to a different area and join a practice that may have a clearer path toward partnership.
I'm sure some of the mega-practices out there (e.g. >20 providers) have more structured pathways to partnership for their young associates. These pathways are probably more analogous to the "partnership" or equity that you obtain via a Kaiser gig. I guess the benefit of these more structured pathways is that they are more well-defined and "guaranteed" since many other associates have achieved it before you. i.e. there is a proven "track record" of this mega-practice giving up equity in a pre-defined manner. The downside is that your equity and control are diluted by having many partners! Personally, I don't foresee myself wanting more than 1 or 2 partners. I guess a practice could always substitute "partnership" with an offering of non-voting shares so that the original partners can stay in control. But I'm sure that breeds some bad blood between the owners of the two classes of stock.
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True to some degree. Some practices that have this well defined set up are not "mega" at all. My group is 8 physicians and I had serious discussions with a group of 5 that had a well defined track. Partnership is absolutely not guaranteed, it's contingent on your performance and subject to change at the time of the partnership offer. While things do get diluted, there are pros to these larger groups as I mentioned. Also in an "eat what you kill" setting the financial dilution is minimal with the advantage of shared overhead costs. There's definitely a heirarchy with senior partners having more of a vote in our practice but overall everyone has a say. It's not formally arranged in terms of shares etc.
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Your numbers for IM and EM long term are high
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This post is comical and a poor attempt at answering the OPs question. The only thing funnier is the attempt at balancing the filler in the post with some " I don't need the money" angle. Sad.
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Lightbox, your posts are informative and provide a important prospective to in training Med students, residents, and fellows / new attendings. So, thank you for the post.
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