Vent - Private Practice Associate

[SouthPod7]

Hey guys,

Hope everyone is doing well. I just want to vent about some stuff at my current job. This is mostly supposed to be self-therapeutic but if anyone has any comments or anything please don't hesitate.

I'm a frustrated associate fresh from residency at a typical, crappy private practice position. My base is less than 90k and my employers are these two significantly older TFPs. The office itself looks like a nursing home, which I get because it is 30+ years old but they haven't put ANY money into renovating it or making it look more appealing, likely because almost all they do are nails/callouses and they are nearing retirement so they figure why bother? All the medications in the cabinets have been expired for
YEARS (except injectables, they do actually stay on top of those). The instruments are so dull and crappy I've had to run from room to room to find ONE usable set of nail nippers that aren't being held together by duct tape. I've had an office chair start smoking and almost catch fire while I was with a patient. That chair is 31 years old and they refuse to replace it. I refuse to see patients in that room. I also have an aggressive non-compete clause in my contract.

I'm also one of those people that doesn't like to have surgery and clinic on the same day. I know, I'm sure a lot of you are saying "Too bad, everybody does that and so should you." My point is that when I was discussing the contract, we agreed that I would get a dedicated surgical day once a week without having to stress about also covering clinic before/after/in-between cases. So, when I have days with 4+ surgeries, the last thing I want to stress about making it back see patients while still having to do op reports and discharge orders and stuff. Now, if I didn't have any cases booked that day? Sure, open it up! It will help off-load my week. But I'm starting to fall into this pattern of rushing clinic and stressing in cases because I'm trying to make it out by a certain time frame. I HATE that, and was trying to avoid it by informing the front desk staff. But the TFPs in charge said that this is not written in the contract (true, my B), and I need to get used to juggling clinic and surgery on the same days. I'm putting it up with it for now because I don't really have a choice and also I need cases for boards.

Also, apparently I am responsible for the entirety of my own marketing. I thought there would be more attempt at notifying the local providers about me from the practice manager? That's definitely what we discussed before I signed anything. Nope, lol. I am now told that I need to drive from practice to practice (on my OWN time) to hand out business cards and try to drum up business. I am somewhat busy, I see about ~20 a day but with the way this office is set up I wouldn't be able to see more without getting another MA, which is very unlikely to happen. I also keep getting pestered (almost) every day about calling the local smaller community hospitals to get privileges so I can go cut toenails for inpatients before clinic (no thanks).

Why did I sign this contract? Mostly personal reasons, but COVID was a huge factor. I'm actively searching for other opportunities however, and I am in discussion with some other hospitals for a job that will actually let me pay off my loans before I'm 60. The only question is if whether I'm gonna be able to push through to finish the 1 year contract or not.

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[Scrantonicity]

Hey guys,

Hope everyone is doing well. I just want to vent about some stuff at my current job. This is mostly supposed to be self-therapeutic but if anyone has any comments or anything please don't hesitate.

I'm a frustrated associate fresh from residency at a typical, crappy private practice position. My base is less than 90k and my employers are these two significantly older TFPs. The office itself looks like a nursing home, which I get because it is 30+ years old but they haven't put ANY money into renovating it or making it look more appealing, likely because almost all they do are nails/callouses and they are nearing retirement so they figure why bother? All the medications in the cabinets have been expired for
YEARS (except injectables, they do actually stay on top of those). The instruments are so dull and crappy I've had to run from room to room to find ONE usable set of nail nippers that aren't being held together by duct tape. I've had an office chair start smoking and almost catch fire while I was with a patient. That chair is 31 years old and they refuse to replace it. I refuse to see patients in that room. I also have an aggressive non-compete clause in my contract.

I'm also one of those people that doesn't like to have surgery and clinic on the same day. I know, I'm sure a lot of you are saying "Too bad, everybody does that and so should you." My point is that when I was discussing the contract, we agreed that I would get a dedicated surgical day once a week without having to stress about also covering clinic before/after/in-between cases. So, when I have days with 4+ surgeries, the last thing I want to stress about making it back see patients while still having to do op reports and discharge orders and stuff. Now, if I didn't have any cases booked that day? Sure, open it up! It will help off-load my week. But I'm starting to fall into this pattern of rushing clinic and stressing in cases because I'm trying to make it out by a certain time frame. I HATE that, and was trying to avoid it by informing the front desk staff. But the TFPs in charge said that this is not written in the contract (true, my B), and I need to get used to juggling clinic and surgery on the same days. I'm putting it up with it for now because I don't really have a choice and also I need cases for boards.

Also, apparently I am responsible for the entirety of my own marketing. I thought there would be more attempt at notifying the local providers about me from the practice manager? That's definitely what we discussed before I signed anything. Nope, lol. I am now told that I need to drive from practice to practice (on my OWN time) to hand out business cards and try to drum up business. I am somewhat busy, I see about ~20 a day but with the way this office is set up I wouldn't be able to see more without getting another MA, which is very unlikely to happen. I also keep getting pestered (almost) every day about calling the local smaller community hospitals to get privileges so I can go cut toenails for inpatients before clinic (no thanks).

Why did I sign this contract? Mostly personal reasons, but COVID was a huge factor. I'm actively searching for other opportunities however, and I am in discussion with some other hospitals for a job that will actually let me pay off my loans before I'm 60. The only question is if whether I'm gonna be able to push through to finish the 1 year contract or not.

Hey man...this sounds pretty horrible--however, it doesn't sound too out of the norm unfortunately. The silver lining is that you're really learning first hand what bothers you/doesn't bother you in private practice. Hopefully you're learning a lot about billing, and what ACTUALLY gets collected. Hopefully you're learning what pathologies you're pretty awesome at treating now that you're on your own, and which ones you need to work on.

I guess I'm saying hang on to that silver lining and use this year to focus on learning what to watch out for in your next position. Now you know some things you should ask for in your next contract. It's pretty rare that you find your career-long position on your first job. Thank God---my first was horrible too, with many of the same issues you've written...some of this stuff you just can't imagine during residency--you just have to experience it, learn from it, and move on. The worst part about it is the non-compete (meaning "move on" actually means "move to another town/state"), but good luck not having one of those in a private practice contract...

 

[619]

I am sorry to hear what you are going through. After going to school for over 10 years, no one should have to go through this. I have a lot to say about your post but I will just keep it short. The question you ask yourself is where you want to be 2,3,4 or 5 years from now. And what moves are you making today to fulfill that goal. You said you are actively searching for other opportunities which is a great idea. Learn as much as you can now in your current practice, so when you land a hospital job as the first podiatrist, you know the things that you will need to set up your own clinic the way you like.

Further more, if you decide to open your own practice, all the things that you are learning now (billing, treatment plan etc) at your current practice will help you. Set a timeline for your self. Let's say till the end of your current contract, if you don't find a hospital job then start looking at opening your own, you may have to stay the second year while you set up your own practice from getting a business bank loan, to finding location, credentialing etc. Stay debt free except student loans, keep your credit score intact and live a residency lifestyle for the first few years.

it is 100% ok to get a business loan on top of your student loan, you will pay everything off with a successful practice. if your current practice office looks like a nursing home and it is somehow still profitable (doing nails/calluses), afterwards they hired you. There is no way you will fail if you decide to open a modern office with your modern training. You have a non-compete so you will have to move. it is not the end of the world, hopefully you are not bound by location and you have some flexibility to move. Hopefully you did not buy a house yet to tie you down at your current location.

 

[heybrother]

This is less for you and more for other people - obviously if you didn't have the contract reviewed by an attorney you should consider doing so. Here's my thing for future people - the person who reviews the contract should not just be a lawyer - they should be a lawyer who has expertise/specializes in contracts related to labor/healthcare/physician contracts, probably ideally for your state.

As for the rest - you have my condolences. It sounds typical. Taped together dull ass nail nippers and all.

 

[619]

In my opinion, except if you have multiple job offers and you can pick and choose, have a lawyer read the contract. If you only have one job contract in the one location that you like, there is really not much negotiation. The lawyer can make all this wonderful changes and suggestions and what will the potential employer do? Take their contract back and tell you to have a good day. You are left without a Job.

The #1 rule of negotiation is the ability to walk away, unfortunately most people can't walk away due to having no other option.

The main part of a contract that can be negotiated is the base pay, % bonus, non-compete distance and maybe vacation time and other benefits, which you don't need a lawyer to do that on your behalf. You speak to your potential employer one on one, face to face, have a friendly discussion and come to an agreement. In most situations, no need for any lawyer to get involved.

For example, If a private practice is not going to offer health insurance. No army of lawyers can negotiate that into your contract. It is not going to happen. But if your non-compete is too aggressive, then a lawyer can help with that.

All this is from the perspective for a PP. Not sure how hospital contract work. I'm sure you need a lawyer for that.

 

[619]

Now you know some things you should ask for in your next contract.

Do you mean next contract in the same practice or next contract at a different job? I doubt much will change in the second year contract in the same job. Maybe a slight increase in base pay to adjust for inflation but don't expect any major changes.
You only aggressively negotiate a second year contract if you have something else lined up. If you have a second option. If you can walk away. If not, then nothing much will change. Just my opinion.

 

[CutsWithFury]

Thanks for sharing your experiences. I really do believe sharing these experiences and talking about the crappy dynamic of private practice podiatry is what will lead the next generation of podiatrists to improving this profession. The more young podiatrists start opening their own practices or join hospital groups the better. If I wasn't hospital employed I would rather go into debt and lose everything trying to start a private practice then work for another podiatrist. It is not worth it. We all worked too hard and trained too hard to be paid less than 100K. It's unacceptable.

 

[dtrack22]

I also have an aggressive non-compete clause in my contract.

Is the non-compete even valid? You would think that someone in a state where non-competes aren’t enforceable wouldn’t put it in a contract, but podiatrists will try. Also, even when non competes are enforceable, they still have to be reasonable. Especially when it comes to healthcare providers since it is generally deemed a community health risk to limit access to physicians. Meaning, physician employees can win non-compete cases depending on the buy out, distance, length, state where you practice, etc. You would need to discuss this with an attorney familiar with contract law in your state. They will tell you wether it’s worth pursuing for free.

I'm a frustrated associate fresh from residency at a typical, crappy private practice position.

If you are fresh out of residency, how are you billing patients? Do you have your individual Medicare number already? If not, was the practice holding your claims or were they submitting claims under the owners PTAN for new Medicare patients that you saw? If so, and the docs didn’t pop in the room to say “hi” to the patient, that’s Medicare fraud. BCBS, Aetna, United, etc. would also like to know if any of their patients were fraudulently billed.

The only question is if whether I'm gonna be able to push through to finish the 1 year contract or not.

The contract is meaningless. You can quit any time you want. So I would be looking to get out as soon as possible. Nothing will change at this job, I promise. Also, if you have no chance of bonusing, stop doing your own marketing and stop doing any extra work. You’re only making them more money. Unless of course you are planning on getting out of or fighting your non-compete and opening up your own place in town. Then establishing some professional relationships would be a good thing.

Good luck on your job search.

 

[air bud]

First thing is finding out if non compete is valid. I talked to a guy in my state that had a 50 mile non compete. Has to leave the city and that literally means he has to leave the state since no other places could support PP. No way that is enforceable

 

[SouthPod7]

First of all, huge thank you to everybody for responding with advice, condolences, etc. I truly wasn't looking for sympathy when I posted that during my lunch break today. I had just gotten so frustrated because one of my employers pulled me aside from my charting to "review how many offices I'm visiting and how I'm planning to make time to reach out more." This is on top of "Did you call hospital X to get privileges? I want you to start seeing those inpatient toenail consults as soon as possible." I said I don't plan on cutting toenails as an inpatient (unless there is paronychia or something related) and that didn't go over so well. I don't like complaining but I just kind of hit a limit today, I guess.

I was also told, for the FIRST time, that I would be taking TWO weeks of call this month for the practice. Of course, I expected to take call for my post-ops, but getting messaged by Aunt Sue on Sunday morning because her toenails are just so painful and she wants to know if she can come in the office after church for a trim because she can't wait until Monday? Hard pass. The on call schedule was literally shown to me less than 72 hours before I was expected to take call for the practice. We never discussed any on call work before I signed my contract. I'm not saying that private practices don't typically have on-call responsibilities, again its just something we never discussed and then was thrown on me.

To answer some points that dtrack and other posters made, my non-compete is significant enough where I would get locked out of my medium sized city should I choose to leave for multiple years, and this was AFTER I negotiated it down (the previous one was even MORE ridiculous). I did have a lawyer review my contract. I think the biggest change they made was making my exit clause more flexible (which obviously was worth it alone). I also asked for the contract to specifically state that I would be eligible for partner after so many years... but they countered with it by adding that I would only be eligible for partnership at their "absolute discretion." They refused to have it stated any other way.

I assume they don't want me as a partner. They make more money off of me as an associate. Something else I didn't realize but I am now realizing is that you bring more value to the practice then just your gross collections. Both of my employers punt me all their wounds and complex patients so they can focus on their chip and clip. I didn't think about it before, but now I'm realizing that alone has significant value, because it makes their work days much easier so they can focus on the easy stuff while still keeping the money in the practice from the surgeries or what not from their more challenging patients.

I did not buy a house. I suspected I wouldn't be at this job after 1 year. I just don't want to jump from crappy associate job to crappy associate job, which is why I'm taking my time now to ensure that my next job is one that I can stay at for years, get my loans paid off, and finally get that F-you money.

Anyways, thanks for reading and contributing everybody. I really do enjoy this community and am happy to have finally joined it.

 

[NatCh]

Damn. Your entire situation SUCKS. So sorry to read about it. I went through something similar twenty years ago when I hired on with a couple of established docs. One of them was okay but the other was a total dipsh**. Every year right around the holidays he would order hundreds of dollars worth of craft bakery foot-shaped cookies to give as presents to referring clinics. Of course he wanted me to drop them off in person WEARING A SANTA HAT. I would eat a few then dump the rest in the garbage. I eventually told him "You're an ass!" then waited to get fired, which is what happened. Leaving that practice was the best move I ever made. Opened up down the street just hoping they would try to enforce the non-compete. Bought a billboard sign for our new practice that was pretty much directly above their office. Suck it.

 

[heybrother]

The whole partner thing was probably a waste of time. The partner verbiage either specifically spells out that you
-will be a partner
-the terms under which it occurs, intolerable, overpriced or whatever
-and what a partner is ie. the degree of ownership, control, profit sharing etc.

or it doesn't matter - in the sense that it doesn't increase your chance of being a partner...

Someone can set me straight on this. You can work somewhere several years and say make me a partner or I quit and it seems like the real question is leverage.

 

[msuDPM]

A VERY different reality than our MD “colleagues” huh? And all of this house talk is amusing to me. What are you buying with an $80K SUB-Physician’s Assistant, Nurse Practitioner salary with a tacked on $2500 amortized student loan payment? A shack? Lol (that’s right, FHA doesn’t give a crap about your $600 IBR payment. They WILL use the fully amortized monthly payment amount in your Debt-to-income ration when qualifying you for a mortgage). You could always go conventional with an even larger 5-20% down payment, however, that won’t help much with that crappy salary. A very different reality than a 1st year FM or IM Attending that’s for sure. We’re not even on the same playing field. I do enjoy the practice of Podiatry but yes, I do wish I could turn back the arms of time. And yes, I do fully expect a crappy experience when the job search comes around in a few months. This is a vent thread right? K, I’m not crazy

Word to the wise, no such thing as "job search comes around in a few months". Start early, contact potential employers often. Takes some luck to dig out of your student loan debt quickly, so try to create your own luck.

 

[dtrack22]

To answer some points that dtrack and other posters made, my non-compete is significant enough where I would get locked out of my medium sized city should I choose to leave for multiple years, and this was AFTER I negotiated it down (the previous one was even MORE ridiculous)

Like I said, a non compete that puts you outside of the city is very unlikely to hold up if challenged. Judges have historically ruled in favor of the community, which means allowing providers to still work in town, regardless of contract language. You need to speak with a better attorney and get a real opinion. If you were dead set on staying in the area, I would honestly consider doing what Natch did and open up shop somewhere in town. You think the guys who pay you $80k are going to pay attorney fees to fight you or just find another sucker to work for them next August? But I get not wanting to risk that.

I think the biggest change they made was making my exit clause more flexible (which obviously was worth it alone)

What does this even mean? What happens contractually if you don't show up to work tomorrow?

I also asked for the contract to specifically state that I would be eligible for partner after so many years... but they countered with it by adding that I would only be eligible for partnership at their "absolute discretion."

So you accomplished nothing...

I just don't want to jump from crappy associate job to crappy associate job, which is why I'm taking my time now to ensure that my next job is one that I can stay at for years, get my loans paid off, and finally get that F-you money.

Unfortunately that means you need to start your own practice or find an MSG job. For the latter you need to be willing to move almost anywhere because of the limited opportunities. Or I guess you could get even more lucky and find a fair podiatry associate job.

We never discussed any on call work before I signed my contract.

So you refused to take call right? At some point you can't complain about your situation if you aren't willing to stand up for yourself. Stop doing stuff you aren't getting paid to do. Stop marketing, stop applying for privileges, don't take call, turn patients away if you don't have the proper instrumentation and tell the patients the reason you can't cut their toenails today is because the owners of the building do not have the equipment for you to do so. You are literally paying them to provide all of these things for you. Unless you're getting 50-60% of collections...but then you'd be a partner and paying your own overhead would actually make sense.

 

[SouthPod7]

Like I said, a non compete that puts you outside of the city is very unlikely to hold up if challenged. Judges have historically ruled in favor of the community, which means allowing providers to still work in town, regardless of contract language. You need to speak with a better attorney and get a real opinion. If you were dead set on staying in the area, I would honestly consider doing what Natch did and open up shop somewhere in town. You think the guys who pay you $80k are going to pay attorney fees to fight you or just find another sucker to work for them next August? But I get not wanting to risk that.

That's good to know. If I was planning to stay in the city, I would probably try to lawyer up and fight it. But I'm pretty dead set right now on getting out of here.

What does this even mean? What happens contractually if you don't show up to work tomorrow?

Well, my contract says I would be "Terminated with cause." I have to give 60 days notice (and continue working and providing services for them for 60 days) in order to... be terminated without cause? I guess? It's kind of unclear. I also live at an at-will state, which I presumed meant I could leave whenever I wanted at any time (just like they could technically let me go whenever they wanted at any time). The terms of the contract can't supersede state law. I also don't really care about burning this particular bridge or whatever. My only motivations to stay right now are to save up enough $$$ for tail coverage and let my lease run out at my apartment.

This is what my contract states:

Termination Without Cause.

"For whatever reason, Employer or Employee
may terminate Employee’s employment under this Agreement upon sixty
(60) days written notice to the other. In such event, Employee will
continue to render services to the Employer and will be compensated as
provided by the Agreement up to the date of termination. If, however,
Employee fails or refuses to continue rendering services, Employee’s
employment shall be deemed immediately terminated."

This does beg the question though, am I legally required to follow my post-ops for their 90 day global period? Meaning if I operate tomorrow, do I have to wait 91 days before I quit?

So you accomplished nothing...

Basically.

Unfortunately that means you need to start your own practice or find an MSG job. For the latter you need to be willing to move almost anywhere because of the limited opportunities. Or I guess you could get even more lucky and find a fair podiatry associate job.

This is essentially what I am doing. I'm giving myself the remaining time on the contract to try to find a hospital-based or MSG job. If all else fails, I may leave and open up shop somewhere else. I'm not sure I could stomach being an associate for another year.

So you refused to take call right? At some point you can't complain about your situation if you aren't willing to stand up for yourself. Stop doing stuff you aren't getting paid to do. Stop marketing, stop applying for privileges, don't take call, turn patients away if you don't have the proper instrumentation and tell the patients the reason you can't cut their toenails today is because the owners of the building do not have the equipment for you to do so. You are literally paying them to provide all of these things for you. Unless you're getting 50-60% of collections...but then you'd be a partner and paying your own overhead would actually make sense.

You're right. I'm not marketing anymore. I'm not taking call. I was originally hedging on getting hospital privileges because I thought maybe it would lead to some more cases down the road, but now I'm learning it's 99% to cut inpatient toenails? I will literally turn those consults away, and ask them to contact my employers who are willing to do that.

 

[dtrack22]

You're right. I'm not marketing anymore. I'm not taking call.

Good. People in these situations need to stand up for themselves. You worked too hard to be treated like a pedicurist for a couple of crusty old podiatrists.

This does beg the question though, am I legally required to follow my post-ops for their 90 day global period? Meaning if I operate tomorrow, do I have to wait 91 days before I quit?

No and no.

Unfortunately, if you want out sooner rather than later its probably going to mean taking another podiatry associate job or starting on your own. Starting on your own gets thrown around a lot on here by people who are employed by MSGs/Hospitals who really don't have any experience in any aspect of managing a practice. Because of that I think it comes off as something that is easy or even feasible for a majority of residency graduates. It's neither of those two things. But if you have the right personality or strong desire to do so, it sure beats all of the alternatives posted in PMnews...

If you do stumble across something promising or have a location you want to go, check on licensing while you are in your current situation. There are many employers and at least one state that require employment verifications which are much easier to get when you can get them done yourself and aren't worried about a former boss being truthful, or even doing it.

 

[PTPuser]

Thank you for sharing your experiences. It really does help open the eyes to those of us who are in school and just starting...no one talks about this stuff. We're constantly force fed the idea and notion of whether we want to be in the profession or not but no one ever talks to you about the grit that it takes to get that job and the machine running to make sure you're doing exactly what you want to do and get paid appropriately for it.

What they're doing to you feels predatory and its just plain sad. But I will use this as a learning experience through your situation.

 

[NatCh]

This does beg the question though, am I legally required to follow my post-ops for their 90 day global period? Meaning if I operate tomorrow, do I have to wait 91 days before I quit?

Your employers would cover the patients during (and after) their global. No abandonment.

 

[josebiwasabi]

Your employers would cover the patients during (and after) their global. No abandonment.

Agree, it's an ethical issue not a legal one.

Legally the other doctors can perform the post op care. However it's probably not great patient care on your part if you do a flatfoot recon and the other doctors in the group only know how to take care of hammer toes post operatively.

 

[NatCh]

Agree, it's an ethical issue not a legal one.

Legally the other doctors can perform the post op care. However it's probably not great patient care on your part if you do a flatfoot recon and the other doctors in the group only know how to take care of hammer toes post operatively.

True, you probably shouldn't do a surgery that your current coworkers can't manage if you know you are about to quit. If one were to get fired or laid off though, then it's out of one's control because you never really know if and when that might happen.

SouthPod7 should do a bunch of really messy surgeries poorly so they'll have gnarly complications then quit and let his employers deal with the carnage. TOTALLY KIDDING. Don't do that.

 

[GreenHousePub]

I would avoid doing any surgeries if you are looking to get out 90 days prior. Because when you leave the practice owners are going to be badmouthing you to the patient, anything that goes slightly wrong will be blamed on you.

It'd be better to do a clean break then get dragged into a malpractice suit.

 

[SouthPod7]

I would avoid doing any surgeries if you are looking to get out 90 days prior. Because when you leave the practice owners are going to be badmouthing you to the patient, anything that goes slightly wrong will be blamed on you.

It'd be better to do a clean break then get dragged into a malpractice suit.

This actually does concern me because the last associate they had they called a bad employee and usually speak poorly regarding him so I can only imagine what they are telling his former patients or post-ops about him. Fortunately my patients seem to like me and I already have some positive online reviews so hopefully that acts as a buffer if they try to bad mouth me to my post-ops or whatever after I leave.

 

[NatCh]

I would avoid doing any surgeries if you are looking to get out 90 days prior. Because when you leave the practice owners are going to be badmouthing you to the patient, anything that goes slightly wrong will be blamed on you.

It'd be better to do a clean break then get dragged into a malpractice suit.

That's a fine point!

 

[ExperiencedDPM]

Damn. Your entire situation SUCKS. So sorry to read about it. I went through something similar twenty years ago when I hired on with a couple of established docs. One of them was okay but the other was a total dipsh**. Every year right around the holidays he would order hundreds of dollars worth of craft bakery foot-shaped cookies to give as presents to referring clinics. Of course he wanted me to drop them off in person WEARING A SANTA HAT. I would eat a few then dump the rest in the garbage. I eventually told him "You're an ass!" then waited to get fired, which is what happened. Leaving that practice was the best move I ever made. Opened up down the street just hoping they would try to enforce the non-compete. Bought a billboard sign for our new practice that was pretty much directly above their office. Suck it.

Wait.....I think your entire story is BS until you post a pic of you with a Santa hat and holding up one of those foot cookies. I can just picture it now.......come on NaTCh. Post that pic and make my day!!!

And then I need you to post a picture of you in the bunny outfit they made you wear for Easter!

 

[HardRoadPaved]

Look to greener pastures SouthPod7. I was stuck in a dead end position / associate mill and dragged it out in hopes it would improve. It didn't and all I got was being overworked and undercompensated. I hit just about every gripe listed as if all these mills have the same game plan: understaff, undermarket, unfair call schedule. Start planning your exit strategy.

 

[G0dFather]

Hey guys,

Hope everyone is doing well. I just want to vent about some stuff at my current job. This is mostly supposed to be self-therapeutic but if anyone has any comments or anything please don't hesitate.

I'm a frustrated associate fresh from residency at a typical, crappy private practice position. My base is less than 90k and my employers are these two significantly older TFPs. The office itself looks like a nursing home, which I get because it is 30+ years old but they haven't put ANY money into renovating it or making it look more appealing, likely because almost all they do are nails/callouses and they are nearing retirement so they figure why bother? All the medications in the cabinets have been expired for
YEARS (except injectables, they do actually stay on top of those). The instruments are so dull and crappy I've had to run from room to room to find ONE usable set of nail nippers that aren't being held together by duct tape. I've had an office chair start smoking and almost catch fire while I was with a patient. That chair is 31 years old and they refuse to replace it. I refuse to see patients in that room. I also have an aggressive non-compete clause in my contract.

I'm also one of those people that doesn't like to have surgery and clinic on the same day. I know, I'm sure a lot of you are saying "Too bad, everybody does that and so should you." My point is that when I was discussing the contract, we agreed that I would get a dedicated surgical day once a week without having to stress about also covering clinic before/after/in-between cases. So, when I have days with 4+ surgeries, the last thing I want to stress about making it back see patients while still having to do op reports and discharge orders and stuff. Now, if I didn't have any cases booked that day? Sure, open it up! It will help off-load my week. But I'm starting to fall into this pattern of rushing clinic and stressing in cases because I'm trying to make it out by a certain time frame. I HATE that, and was trying to avoid it by informing the front desk staff. But the TFPs in charge said that this is not written in the contract (true, my B), and I need to get used to juggling clinic and surgery on the same days. I'm putting it up with it for now because I don't really have a choice and also I need cases for boards.

Also, apparently I am responsible for the entirety of my own marketing. I thought there would be more attempt at notifying the local providers about me from the practice manager? That's definitely what we discussed before I signed anything. Nope, lol. I am now told that I need to drive from practice to practice (on my OWN time) to hand out business cards and try to drum up business. I am somewhat busy, I see about ~20 a day but with the way this office is set up I wouldn't be able to see more without getting another MA, which is very unlikely to happen. I also keep getting pestered (almost) every day about calling the local smaller community hospitals to get privileges so I can go cut toenails for inpatients before clinic (no thanks).

Why did I sign this contract? Mostly personal reasons, but COVID was a huge factor. I'm actively searching for other opportunities however, and I am in discussion with some other hospitals for a job that will actually let me pay off my loans before I'm 60. The only question is if whether I'm gonna be able to push through to finish the 1 year contract or not.

I just read ALL of this ... im sorry about this situation given the circumstances around covid you would have gotten something better but you had to make with what is available ... its crazy how people run their office like this .... its very inexpensive to get right equipment and compensate people correctly ... a good employee/associate is not an expense but an asset .. in the long run these offices just end up loosing

 

[HardRoadPaved]

Please elaborate on your road to greener pastures and what the outcome was

Simple. I followed the rules on escaping. Didnt buy the fancy doctor house with the 0% money down loan. Didnt buy the fancy car. No frivolous spending. Saved up and was able to use that money to open my own practice. I knew I had to escape the associate game. No investment in my success. This was a pattern with others. I recognized it and no one is gonna take care of you or your mental health but yourself.

 

[NatCh]

Wait.....I think your entire story is BS until you post a pic of you with a Santa hat and holding up one of those foot cookies. I can just picture it now.......come on NaTCh. Post that pic and make my day!!!

And then I need you to post a picture of you in the bunny outfit they made you wear for Easter!

Is it Christmas again already?

 

[dtrack22]

Work for $90K as an associate in my desired local and save at a much slower rate?

Only if non-competes are illegal in your state. Or if by desired local you mean, region or state and not city. If you don’t have the guts or desire to fight a non compete, most podiatry group non competes I’ve seen will basically push you out of town. If you want to go somewhere specific in the long run, I wouldn’t jump at an associate job in the same area unless your contract allows you to set up across the street whenever you want. Then it would be beneficial to get started in the same town you want to end up in because you will have some goodwill and a patient base for the new clinic.

If you don’t mind, how much did you save up to open your practice? I asked 1 Attending and they recommended $70K to start.

Since I started with around that (and haven’t run out yet), I’ll tell you the only reason I was able to was because I joined an office that was completely furnished and allowed me to use any supplies/equipment I needed. I bought a handheld ultrasound and some ingrown toenail specific instruments and some pre-fab inserts and that was it. I was able to mostly do my own website because I had family help and I’m semi-rural without competition which means I can get on the first page of google with minimal effort (ie less $ for AdWords and less concern for SEO). If you are in a larger metro, you will pay $7-10k for someone to do that for you. Your payroll should consist of a front desk person only, no MA until you need one. I didn’t even have to pay the front desk gal as ortho let me use theirs until I am busy enough that she can’t cover both clinics. I didn’t pay myself for a month or so, and even then it will be $4-5k to cover family living expenses and make loan payments. You have to be able to minimize all aspects of your payroll, including owner draw.

if you need to buy chairs and an X-ray unit and hire multiple staff and you need $10k/month for yourself right away, and you need to out market your competition because the area is more saturated, etc...then $70k is gone by your second month and you still haven’t brought in more $ than what patients have paid you in copays.


Of course as I started my practice the local hospital CEO was replaced and so the hospital/MSG ortho group became free to hire me which they have offered. So I’m also in a position to where if I did run out of money quickly I don’t care because I can sell my practice in the next few months and become a salaried employee. The hospital/MSG feeds me referrals without any effort on my part so I have spent nothing on marketing. I don’t need to and that’s within a month of opening. Another thing that helps when you are talking about starting with $70k. Honestly most people would have trouble doing it, IMO.

oh yeah, I pay for my phone line but not for internet, didn’t need much computer equipment, I do spend more than most on my EMR but it allows me to get away without MA/billing help for quite a bit longer than most would want. Any ways, it’s easy to spend $50-60k before you even open your doors...I spent $6-7k and could still blow through $50-60k more before I have enough monthly revenue to cover expenses.

 

[HardRoadPaved]

If you don’t mind, how much did you save up to open your practice? I asked 1 Attending and they recommended $70K to start.

Since COVID most banks are likely not going to lend you money with no practice history.

I think its pretty arbitrary to list a number since no two DPMs run the same practice. I personally dont want to work in a dump with 30 year old podiatry chairs that you have to apologize for when the foot component wont elevate and you are cutting toenails essentially sitting on the floor.

As for general guidelines: are insurance panels open in the area you want and also figure out all of your fixed costs now. This includes rent in the area you want per sq foot. Loopnet.com will give you ideas but feel free to do what I did and drive around looking at for lease signs on buildings where you want to be. I picked a range of 1750-2250sq feet when I started my search. Then from there your office is not going to be the way you want it. Thus you need tenant improvements. Expect a shell buildout to be anywhere from $60-120sq foot to build out and as you can see your 70k dwindles without contribution from your landlord.

So now you've got a place and hopefully your amazing broker will negotiate free rent you can use in the beginning of your term. Now think of everything that's gonna cost in that space and start with the big ticket items. Malpractice insurance varies pretty vastly depending on what state you're in but you'll need $1m/3m in coverage and be listed for "major surgery." If you're working already expect to cut a big "tail check" or have it tacked onto prior acts coverage. Xray 25-35k as youre gonna have a DR system. Chairs... big range depending on how nice you want it 5k-12k each. Furniture? Artwork? Autoclave? Business insurance? DME you're keeping on the shelf? Instruments.. how many nippers, packs do you want? The list goes on....

 

[SouthPod7]

Is it Christmas again already?

View attachment 320556

"Really Phyllis? An oven mitt? How is this better than an iPod?"

 

[dtrack22]

Since COVID most banks are likely not going to lend you money with no practice history

Good point. Bank of America suspended their practice solutions program. At least the start up division. They were still doing acquisitions for established offices trying to acquire additional practices/offices. But that means you either have to do an SBA or you have to have a fair amount of money/collateral yourself (or some family with money).

 

[619]

Good point. Bank of America suspended their practice solutions program. At least the start up division. They were still doing acquisitions for established offices trying to acquire additional practices/offices. But that means you either have to do an SBA or you have to have a fair amount of money/collateral yourself (or some family with money).

Where did you get the insider information from. Nothing says that on BOA website

Physician & Optometry Practice Loans from Bank of America

Discover physician and optometry loans from Bank of America. Learn how you can start or expand your practice and purchase new equipment to meet business needs.

www.bankofamerica.com

 

[HardRoadPaved]

Where did you get the insider information from. Nothing says that on BOA website

Physician & Optometry Practice Loans from Bank of America

Discover physician and optometry loans from Bank of America. Learn how you can start or expand your practice and purchase new equipment to meet business needs.

www.bankofamerica.com

Not really insider information but I dont think banks want to advertise they are closed for business actively. Call bank healthcare solution departments in your region. All of them said Q2 they shut down and basically froze new practice start-ups.

I want to make it clear there are other alternatives to a traditional bank loan. Lets say you get 70k to squirrel away to open.

Rent- look for a place you want to be now. think about what parameters you want in a place... first floor strip mall? beautiful lobby high rise? Auxillary building next to a hospital? it takes quite a lot of time to negotiate the right terms of a lease. also if you bring in a broker they can assist in your search. look to landlords that will either take care of turn keying your transition with reasonable tenant improvements (new flooring, fresh paint). Then try to see if you can get a free month of rent for each year you sign a lease. most places want a 3 year commitment. just dont be shocked that most landlords want a personal guarantee if they are going out of a limb for you.

Equipment- ebay, dotmed. just go used. just be ready for things to not work out. look into medical office repair companies in your area. you can hold out the x-ray machine or look to equipment loans if your credit is good enough.

Malpractice insurance- most let you pay in installments for a new plan so instead of forking over money from tail just pay a prior acts coverage over time.

Hospital privileges- just start off with one facility. you need this for insurance credentialing anyway.

Payroll- be your own MA to start. dont be above menial tasks. just get a good EMR and dont get something that doesnt make your efficient since price between a good one and a bad one is in the hundreds.

Credentialing- do it yourself. CAQH, NEPPES, Medicaid. Its time consuming but not rocket science.

Bookkeeping- quickbooks, also not rocket science.

Really do a map of everything you'd need before you open and you'll see its not overwhelming but it is a lot.

Home expenses- just be frugal.

 

[dtrack22]

Where did you get the insider information from. Nothing says that on BOA website

Physician & Optometry Practice Loans from Bank of America

Discover physician and optometry loans from Bank of America. Learn how you can start or expand your practice and purchase new equipment to meet business needs.

www.bankofamerica.com

I spoke with them directly in July and again in August...

At the time their website did not mention it but the representative made it very clear. So unless your insider information Is from September or October then I would imagine they are still not lending to start ups. I also could not get a business credit card in August due to covid. Oh, and most doctor mortgage programs were no longer being offered in June/July (was looking at refinancing).

 

[GreenHousePub]

Where did you get the insider information from. Nothing says that on BOA website

Physician & Optometry Practice Loans from Bank of America

Discover physician and optometry loans from Bank of America. Learn how you can start or expand your practice and purchase new equipment to meet business needs.

www.bankofamerica.com

Frozen till at least January, we were looking at starting a new practice. Spoke with a local BoA VP for healthcare startups.

Loans to buy out existing practices is still on the table if you're interested in getting ripped off. In that case I'd wait until next year when they file their taxes. They'll have to account for the lost business and it'll lower their appraisal value.

 

[619]

Check Well Fargo. They are still doing the business loan for new practices. Although it is taking longer than usual. PM me for details.

 

[619]

Credentialing- do it yourself. CAQH, NEPPES, Medicaid. Its time consuming but not rocket science.

I agree with everything you said but I will suggest to have someone, with experience, take care of insurance credentialing for a new practice. I assume as a practicing doctor, you already have CAQH and NPPES set up even as a resident when you applied for NPI.

Insurance credentialing will be both for you as a doctor and also credentialing for your new practice under your new practice name and tax ID.

Furthermore, setting up an LLC, getting a EIN number etc can all be done by yourself. You don't need a healthcare attorney for that

Lastly, using quickbooks for book keeping is wonderful and easy to use but still get a good CPA.

 

[Investing Resident]

Does anybody have any opinions on using a consulting service such as Pinnacle to help start a practice from scratch? Is adding another 10-15K of start-up cost worth it in the long run?

 

[HardRoadPaved]

Does anybody have any opinions on using a consulting service such as Pinnacle to help start a practice from scratch? Is adding another 10-15K of start-up cost worth it in the long run?

I think its a waste of money. I think running a business is just something you have to learn. I dont think you can fluff that road and expect just because you hire a consultant you wont have hiccups. Also these national consultants wont know the local market and regulations like you do. You're better to vet clients like a general contractor for your office, a credentialing firm, EMR companies, medical billing that claim "we only take 6% flat as a good deal" then stuff hidden charges."

check out this ophthalmologist blog: Solo Building Blogs Most of the articles are free without going through the pay wall.

 

[Investing Resident]

check out this ophthalmologist blog: Solo Building Blogs Most of the articles are free without going through the pay wall.

This is a great resource and a fantastic insight on starting a practice. Thanks for the recommendation.

 

[Creflo]

The original post sounds almost exactly like where I did my residency. Old, dull nail nippers left my hands hurting. Chairs about to fall apart. Your hands are your future, go buy yourself some nice pairs of nail clippers to use. My first associate job was straight percentage of receipts and they would give me charity cases, saying it is "the right thing to do." And the medical assistants would show up late. There's nothing like working for yourself, but you have to jump through the hoops to get there. Thankfully there are a lot of great people on this forum to help you.

 

[Feli]

Many good points made already...
I am all for private practice, but if you signed with those guys having seen everything you now complain of (outdated office, crummy instruments, mediocre pay, etc)… do you think you are ready to fly solo? You didn't eval them very well pre-contract and didn't learn much from them aside from how not to do things, right?

Consider what you might learn from a well run office. If you read RDPD and similar, that exp and mentorship can be worth more than the money if you get numbers for ABFAS, get tips and tricks from skilled priv prac guys, etc. You can always start on your own later...
I have had various priv prac jobs from where I was the hardcore surgeon and the owner very business savvy yet forefoot only, one where I was the sapling among a few other well trained and more exp RRA guys with the big kahuna surgeon a program director doing TARs etc, then a stint where I was the only one who did any surgery and the others were pure C&C stuff, and one where I was the only pod in a sea of MDs. All can work... you can learn in all. Some marked fantastic, some did great work, some were fantastic at an endless sea of referrals, etc.

After my first job, was mad too. I said "eff this, I'm starting a new office with digi XR, clean EMR, great website, blah blah." I got approved for $300k and said that no way, no how was that enough to start up from scratch, market, and keep a decent private afloat until it was profitable. According to my biz plans, that probably wouldn't allow me to pay rent and staff for even 3-6 months before I'd be worried about staff paychecks clearing (and it can easily take a couple months from first patient to first checks coming in). It all depends if you want to start with some retiring doc's garbage or if you want to buy a winner or start one. I know it can be done on the cheap, but is that what you want? There is nothing wrong with another associate job... but pick a group where you respect their skills, they have the rep/marketing you like and can learn with, and they are hiring you since they're legitimately just too busy. GL

 

[HardRoadPaved]

I got approved for $300k and said that no way, no how was that enough to start up from scratch, market, and keep a decent private afloat until it was profitable. According to my biz plans, that probably wouldn't allow me to pay rent and staff for even 3-6 months before I'd be worried about staff paychecks clearing (and it can easily take a couple months from first patient to first checks coming in). It all depends if you want to start with some retiring doc's garbage or if you want to buy a winner or start one. I know it can be done on the cheap, but is that what you want? There is nothing wrong with another associate job... but pick a group where you respect their skills, they have the rep/marketing you like and can learn with, and they are hiring you since they're legitimately just too busy. GL

Now if you truly do the marketing and find an underserviced (and I dont mean poor, just less dpms around) area then you're set. Want to open on the 10th floor of a building in a major city with a dpm on every block.... then rethink. I said above real estate is the rate limiting factor and it takes FOREVER to find the right location and the right landlord. This isn't residential real estate where you can just browse apartment listings and sign without reading much of the boilerplate lease.

In terms of seeing a paycheck, this is why you need to live below your means. No fancy car, no fancy doctor house. If you can drop major expenses before going into solo practice then those 3-6 months wont suck as bad. Its when you have a nice lifestyle and cutting back will make your spouse and kids miserable if they are privy to a more comfortable living.

Winner practices come from winner doctors who always strive to be better. Cant just buy a winner practice and hit cruise control. Also if you watch every piece of the puzzle come together in a start-up you'll know how to run it more efficiently.

 

[G0dFather]

Winner practices come from winner doctors who always strive to be better. Cant just buy a winner practice and hit cruise control.

I like this... this is so true ...always stay HUNGRY!