Searching for some guidance regarding future FP life...help!

[cabound]

Sorry for the long post, but please bear with me as I work through my thoughts through words! I'm currently finishing my second year of FP residency alongside my husband who is IM. We have a baby on the way due in November. We are both interested in integrative medicine for the underserved and are looking to pursue additional fellowship training alongside our immediate post-residency jobs with a long-term goal in mind to open a holistic clinic together. We currently have a total of $250K in loans with minimal contributions to a 403B. We're trying to decide on the best course of action for the 1-2 years following residency to enable us flexibility for our first child and to obtain some integrative medicine training on the side (a few weeks out of the year for on-site training.)

With $250K in debt, we fear both mortgage loans and startup costs for a private practice will make this unrealistic, so we have come up with the few options (and caveats):

1. Working for an underserved center and applying for the NHSC loan repayment program. Problem is, we will have to accept a contract before knowing if we get the repayment - and it seems on SDN this has been difficult to obtain from others' experiences. Also, with my maternity leave, I will not qualify for the first year following residency since I have to start work in July 2015.

2. Locums for flexibility and competitive pay - problem here is having to buy health/life/disability insurance on the side and manually setting aside money for taxes. Also, I am just made for the ambulatory life - which I believe will be less than affordable.

3. Find jobs in our geographical interests and pay IBR on our loans for 25 years and just take more loans our for a house/practice.

4. Find a "public service organization" (still unsure what qualifies - but part of our residencies will since we worked for a non-profit).

I know this is a loaded thread, but we both feel confused about what our next best steps should be and don't know where else to turn. Old school docs were from a different era, and just a decade ago, student loans were at a 2% interest rate, so didn't necessarily determine your next steps. Thank you, anyone, in advance for any helpful advice!

Peace and love

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[DIce3]

I want to be of assistance. Tell me first, what fellowships will you two be pursuing? What are your long term plans with integrative medicine?

 

[Smokemont]

Just a M3 here and going to likely tell you something you already know. The first thing that jumped out to me was that you'll have 250k total between 2 physcians. Obviously having a baby complicates this but why not work full time for ~1yr, live cheap and pay down a substantial amount of that debt?

 

[cabound]

Dice3-

We plan on doing the Andrew Weil fellowship out of AZ that is a distance training for 2 years requiring 2 weeks/yr of travel to AZ (although I believe some if not all of this qualifies for CME). We are also pursuing medical acupuncture through the Helm institue in UCLA. Again, this is distance requiring 3 5-day on campus trainings. Long term we hope to start our own primary care practice using integrative medicine to help promote wellness. We've talked about finding a "coalition" of sorts - nutritionist, social worker, etc... Maybe even a community farm.

Smokemont-

Thanks for your response. Absolutely that's an option as well. We don't plan on buying a house and/or practice right away and will hope to pay down our loans.

 

[styphon]

NHSC loan repayments are based on a proper application and the need of the community. If you look on the website, they have a link with scores for each site (if the site qualifies). They mention that sites with scores <4 never really get the repayments...

By using this list and interviewing at places in the area you work - you can include the NHSC score within your decision making. If a site has a 9 (I think the highest need score), you are almost set on getting this.

Lets say you both start off with this new practice - your inital patient load is 0 - but your loans will kick into repayment, and you will still have to pay rent/mortage at your site. In the beginning you would need to get additional loans - or work elsewhere - to cover living expenses/loans/rent.

 

[cabinbuilder]

2. Locums for flexibility and competitive pay - problem here is having to buy health/life/disability insurance on the side and manually setting aside money for taxes. Also, I am just made for the ambulatory life - which I believe will be less than affordable.


What do you mean by ambulatory life? Meaning you like to be home? Or travelling doesn't bother you? Buying your own insurance is easy but I never did it with a new baby so not sure if you would find one that covers well child checks and shots, etc. However, on the adult side, if you don't have any major medical issues you can just buy catastrophic and do like I do, pay the $150 for my yearly visit, get my Rx filled and move on.

The thing with locums is you can make big money quickly BUT it take a lot of time and hours to do that. 250K in debt is not that much for both of you. I have that myself. I don't know how locums would work with a baby. Most sites require minimum of 2 month commitment due to credentialing it takes to get you on board for them to get paid. I work on the low end 40hr/week and the high end 80+ depending on the job need. My WEEKLY income (before taxes) is 3500 - 9500 again depending on the hours and the hourly wage. Locums pays for your travel to/from home, your malpractice, your housing at the site, and your rental car. Not sure if you would plan to take the baby with you, would need a nanny to go with. On the flip side, you would be able to set your own schedule and work when you want and be off when you want.

Be sure to see my locums how to guide for other how to tips.

 

[DIce3]

Since there are two of you starting in primary care, it would seem to make the most sense to me to start up your own two person primary care practice with no additional strings attached. I would probably avoid boxing yourself in with a contract for loan repayment(#1,2,4). I would just start a two man practice and work off the debt on your own terms. I think I would hold off on the extra training for now and focus on building a solid practice and then decide over time, how to optimize it. I would very strongly advise against all the other ideas discussed in your posts; stick to a very simple business plan: you=primary care physician as your own boss with no strings. I suspect that once you are crushed in two years by an overwhelming patient load, you will be glad you kept it simple.

 

[cabound]

Styphon -
The HRSP score needs to be at least 14 for the max repayment. We were just unsure of making the commitment to be in a rural area without knowing with some certainty (or some confidence) that we will likely get some assistance. I realize $250K isn't as bad as some have it, but the thought of taking out additional loans on top of our loans to get started seems daunting - esp without a salary to start.

Cabinfever -
Ambulatory meaning outpatient work, and yes, I prefer to be at home for baby's sake and not travel. That being said my husband may be more flexible. And isn't there an opportunity for finding a locums job in a certain pre-defined radius and not travelling around if you don't want? Not sure about baby insurance quite yet either...

Dice3-
Only concern again is principal investment for starting a practice and starting from ground zero while we build a patient base without a solid income. Plus, it takes time to build your staff, etc...don't know if we could jump right in. That's why we were looking for a 1-2 year job commitment to save/help pay down loans while preparing for the bigger step after.

Thank you all so much for the advice so far - we really, really appreciate any thoughts/suggestions!

 

[VA Hopeful Dr]

My advice...

One of you start the practice, the other find a job that will pay well from the start (I'm thinking hospitalist for the IM doctor). Once the practice is doing well, have the other join it.

Alternately, both find existing jobs, blitz the loans, save up some, then start the ideal practice in the manner I suggested. With 1FM and 1IM, you could do that comfortably in 4-5 years. Possibly less if you live in an area with a reasonable cost of living.

 

[DIce3]

When I first started out, I had one cellphone, one fax, and one exam room than I sublet on afternoons only (I was a cheapskate eh?) You can really start a practice on almost nothing. I did not hire my first employee for 13 months.. by then I realized I made a mistake waiting so long and needed more than one employee. Having one of you start the practice and the other do locums/moonlighting/hospitalist/etc is a great idea. Wonder if you can take unassigned hospital call at your hospital and funnel no doc patients back to your new office. You should decide now what age of patient you will start with so you can cross cover each other.

 

[cabound]

VA Hopeful and Dice 3 -

Thank you so much for your advice. These are the two strategies we keep coming back to. You have no idea how much it helps to hear another physician with some experience glean some insight on our thoughts.

 

[SuckySurgeon7]

OSU has a manual for starting a practice in a rural location that has some good info in it. It's one perspective out of many, but it does give some helpful math. Also included is a similar manual for operating a direct primary care practice. Hope it helps and good luck!

 

[DIce3]

The Rural Physician Clinic Guide is great! There are some numbers in there I had never seen. If anyone has any other guides about opening/running a practice, I would love to see them. I have found Medical Economics to be of use but we really need some better how to manuals about opening/running a practice. While this is year 13 in the wild for me, I am constantly struggling as I never earned an MBA.

Thank you

 

[cabinbuilder]

Cabinfever -
Ambulatory meaning outpatient work, and yes, I prefer to be at home for baby's sake and not travel. That being said my husband may be more flexible. And isn't there an opportunity for finding a locums job in a certain pre-defined radius and not travelling around if you don't want? Not sure about baby insurance quite yet either...
Yes, there are opportunities for locums closer to home (in theory). Depends on the state and the need. It may be difficult to have consistent work if you limit your radius as the jobs may not be there AND there is no guarantee that a site will accept you as their locums provider. Now, if you live in a big state with large rural areas: Texas, NM, AZ, CO, MT, OR, AK, CA then there are and abundance of jobs. Texas generally has the most jobs available at any given time.

 

[xenotype]

You could split a single hospitalist position between the two of you and start the practice at the same time. A single hospitalist position will easily support your costs and loans if you start the practice like dice with minimal overhead. I'll have more than that by myself when I am done. As for the integrative part, http://www.integrativeasheville.org/ is an example of a highly successful DPC practice in a somewhat rural area that does exactly what you want to do.