What job do I go with?

[WhatJobDoIPick]

Throwaway account.

Currently working in a hospital employed job for about 3 years. I really don't like it and I am increasingly burnt out. I have an opportunity to join an SDG. Hoping for some guidance as to what the right move is. Below is a quick overview of the salient points of each gig:

Current job:
-Hospital employed, W2
-No nights (currently - definitely not a guarantee moving forward if they lose nocturnists which they very well may as they are mostly all burnt out)
-No control over work environment
-Very poor leadership
-Pay stagnant since COVID (however, older people working here make 100-200k more than I do for less productivity)
-Poor retirement benefits (just a standard 403b with a very small match; no 457b or anything else)
-Extremely high wait times, leading to agitated and dissatisfied patients who take their frustrations out on staff.
-Very slow lab and imaging turnaround

New Job:
-2.5 yr prepartner track during which you are W2 employee
-More hours than old job
-About a 20% hourly paycut during prepartner phase, overall similar gross pay due to more hours required
-Pay obviously goes way up when partner with very strong retirement and tax benefits
-Seem to have a good track record of granting partnership
-Have to work nights (ugh)
-Longer commute (30 min vs 15)
-Much more control over things (when partner)
-Leadership seems very supportive and really has their finger on the pulse of things going on in their department - much greater sense of actually caring about their physicians and patients

Essentially my burn out is the result of a few things:
1) Lack of control
2) Seeing legacy employees make way more than me at current job, while I run circles around them productivity wise
3) Exposure to bad leadership

I see the conditions at my current job progressively worsening, and not getting better. If I stayed there for 20 years, I would certainly look back on my career as a waste of time.

Essentially by taking the SDG job, I am taking somewhat of a lifestyle hit (more hours, more nights) in exchange for better leadership, better environment, better pay and control (as a partner), and ability to retire much earlier later on. The risk, obviously, is that I am not granted partner, or that the group fails or is bought out. Group failure is always a possibility, however they are currently expanding and seem to be very well equipped to innovate and deal with changes that CMS and other insurers bring. Group buy out is also a possibility, however PE groups seem to be fleeing the area of the county that I am in.

Any sage wisdom is appreciated.

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[bravotwozero]

Large CMGs aren’t really in a position to buy out SDGs at the moment, so I wouldn’t worry too much about that.

Given what you’re saying, the sdg seems like a better deal. I’d ask to see the books.

 

[BoardingDoc]

Throwaway account.

Currently working in a hospital employed job for about 3 years. I really don't like it and I am increasingly burnt out. I have an opportunity to join an SDG. Hoping for some guidance as to what the right move is. Below is a quick overview of the salient points of each gig:

Current job:
-Hospital employed, W2
-No nights (currently - definitely not a guarantee moving forward if they lose nocturnists which they very well may as they are mostly all burnt out)
-No control over work environment
-Very poor leadership
-Pay stagnant since COVID (however, older people working here make 100-200k more than I do for less productivity)
-Poor retirement benefits (just a standard 403b with a very small match; no 457b or anything else)
-Extremely high wait times, leading to agitated and dissatisfied patients who take their frustrations out on staff.
-Very slow lab and imaging turnaround

New Job:
-2.5 yr prepartner track during which you are W2 employee
-More hours than old job
-About a 20% hourly paycut during prepartner phase, overall similar gross pay due to more hours required
-Pay obviously goes way up when partner with very strong retirement and tax benefits
-Seem to have a good track record of granting partnership
-Have to work nights (ugh)
-Longer commute (30 min vs 15)
-Much more control over things (when partner)
-Leadership seems very supportive and really has their finger on the pulse of things going on in their department - much greater sense of actually caring about their physicians and patients

Essentially my burn out is the result of a few things:
1) Lack of control
2) Seeing legacy employees make way more than me at current job, while I run circles around them productivity wise
3) Exposure to bad leadership

I see the conditions at my current job progressively worsening, and not getting better. If I stayed there for 20 years, I would certainly look back on my career as a waste of time.

Essentially by taking the SDG job, I am taking somewhat of a lifestyle hit (more hours, more nights) in exchange for better leadership, better environment, better pay and control (as a partner), and ability to retire much earlier later on. The risk, obviously, is that I am not granted partner, or that the group fails or is bought out. Group failure is always a possibility, however they are currently expanding and seem to be very well equipped to innovate and deal with changes that CMS and other insurers bring. Group buy out is also a possibility, however PE groups seem to be fleeing the area of the county that I am in.

Any sage wisdom is appreciated.

Everyone talks about "making a ton once partner" and yet it seems rare to actually know what that is. Hard to make an actual comparison without that data. Agree with @bravotwozero in that I would want more data about what partners make. Even if they come back saying that they can't give you that data, you could probably get them to answer something like "what is the lowest amount a partner would reasonably make."

The commute isn't a huge deal IMO. I used to live 15 min from my shop but moved a couple of years ago and now live 30 min away (sound familiar?). There is another shop that I also used to work at which is 15 min from my current house. I could work there. I don't. The better job is easily worth an addl 30 min in the car/day.

Nights are a bigger deal. The fact that you might lose your nocturnists makes that something of a moot point. Is the new group looking to hire more than one doc? Do they want to poach one of your nocturnists that you like (something to bring up with them once you've already secured the job obviously)

 

[WhatJobDoIPick]

Everyone talks about "making a ton once partner" and yet it seems rare to actually know what that is. Hard to make an actual comparison without that data. Agree with @bravotwozero in that I would want more data about what partners make. Even if they come back saying that they can't give you that data, you could probably get them to answer something like "what is the lowest amount a partner would reasonably make."

The commute isn't a huge deal IMO. I used to live 15 min from my shop but moved a couple of years ago and now live 30 min away (sound familiar?). There is another shop that I also used to work at which is 15 min from my current house. I could work there. I don't. The better job is easily worth an addl 30 min in the car/day.

Nights are a bigger deal. The fact that you might lose your nocturnists makes that something of a moot point. Is the new group looking to hire more than one doc? Do they want to poach one of your nocturnists that you like (something to bring up with them once you've already secured the job obviously)

That's a good way to ask the partner pay question. I'll do that.

It's hard to get a solid answer on the actual cash once you reach partner, but I do know they max out your 401k to the IRS limit, contribute to a CBP for you, pay your state income taxes, and heavily increase CME funds (enabling you to run lots of expenses through the company).

The nights are a tricky thing. There is no contractual protection against nights in my current job. I am protected simply because we currently have nocturnists willing to eat the shifts. One of the nocturnists is a powerhouse and literally works every single night (they work at multiple places). He is not human. He has four children, is in his 40s, and I know he will eventually want to cut back. The other two are burnt to a crisp and always talk of leaving (although who knows how serious these threats are - can't be that serious as they are still here, however everyone has a breaking point I guess). We hired a new nocturnist a few months ago and he promptly put in notice 2 months after starting after experiencing the work conditions.

SDG says they are seeking to hire more nocturnists to decrease the night burden on everyone else, but who knows.

 

[Groove]

The fact that you have a gig where you don't have to work nights is a massive deal to me. That alone is worth 100K annual compensation as far as I'm concerned. The fact that you aren't protected in your contract is kind of moot since it has essentially become an entrenched pattern in your group. None of your day docs have had to work nights. There would be a massive revolt and demand for FT nocturnist if any of your night guys left. Much more so than if you were in a group where everyone had been expected to pull nights each month. As a hospital employee, negotiating a FT nocturnist with c-suite would be MUCH easier considering other service lines do the same i.e. hospitalists, etc.. That kind of request would probably seem very natural and obvious to hospital executive leadership considering they are probably oblivious that our specialty routinely demands overnight shifts.

I don't hear anything about this new job that's worth leaving your old one. The poor wait times, bad leadership, etc.. is everywhere you go. Leadership generally cycles every few years. More hours required + forced nights + pay cut for 2.5 years is a deal breaker for me. I'd recommend staying put. Hell, send me a PM when you're ready to leave so I can take your old job!

 

[turkeyjerky]

So I'm currently about a year into a partnership tract that saw me take a big paycut to work all nights. Overall, I don't regret it. More functional department, happier collegues and I'll make it up and then some w/in 3 years on the back-end.

It sucks that so many SDGs exploit their new hires like this, but what are you gonna do?

 

[emergentmd]

Not to be pessimistic, but

New Job:
-2.5 yr prepartner track during which you are W2 employee. That is a long tract, many things can and will happen in that period.
-More hours than old job. Ughhhhh
-About a 20% hourly paycut during prepartner phase, overall similar gross pay due to more hours required. Ugggghhh its a paycut.
-Pay obviously goes way up when partner with very strong retirement and tax benefits. If pay goes up by that much then they are really screwing pre-partners. There is downward pressure on reimbursement with NSA, in 2.5 yrs SDGs may be begging to be employees.
-Seem to have a good track record of granting partnership. No guarantees what group looks like in 2.5yrs.
-Have to work nights (ugh). Big Ugghhh
-Longer commute (30 min vs 15). Longer hours, more pts, night shifts and that extra 15 min feels like an hr.
-Much more control over things (when partner). I don't know what this really even means. Hospitals still own you. SDGs have very little control over anything other than scheduling. The metrics, pt sats does not go away.
-Leadership seems very supportive and really has their finger on the pulse of things going on in their department - much greater sense of actually caring about their physicians and patients. Ugghh. This is a mirage and not sure what pulse you are talking about. I was dept chair of my SDG 8 yrs ago which was still the golden years of EM and looking back, I had zero control.

 

[cyanide12345678]

This is the wrong way to approach this situation.

The jobs are similar. They have their pros and cons. What matters is what are your goals in life. What do you value in your life? Money? Time? Do you have kids? Do you have a spouse? What is your net worth - is making more money even important anymore to you? How much do you value your health, circadian rhythym disruptions can definitely take a toll on the body. So really…. Think about what you want in life.

A colleague of mine had his cancer come back recently, what would you value if tomorrow you got diagnosed with something bad?

Here’s a personal example from my life. With my first job, i was in debt, broke, and money mattered. I didn’t care about commute, i didn’t care about volume, i didn’t care about administration, i went to the job that paid the most, even became a nocturnist to maximize my income. That’s what mattered to me.

Now that i have money, i would never work my old job again. It’s not worth it anymore. I took a massive paycut at my second job, but i see 30 ish percent less volume. So money just didn’t matter as much a few years later.

Once i hit 2-3m in net worth i might even just go part time doing telemed, take another paycut, but get control in my life.

So the question isn’t which job is better, technically on paper if you are guaranteed a partnership and the group doesn’t dissolve then sdg Is better. But who knows what the future holds. The real question is…. What do you want ? What stage of life are you in? What’s actually important to you? If you have diaper wearing children, nights and more hours might not be for you. If you a single person with no responsibilities then do whatever you desire.

Good luck.

 

[turkeyjerky]

For some reason, I read your initial post as indicating you'd have to do all nights as a prepartner in the new job, looking over it again it looks like you just have to do your share. That, imo, makes this a no-brainer. In 3 years, hospital is going to be cutting pay by 20% each year and they'll be a line of mcHCA grads out the door waiting for a chance to work there.

 

[WhatJobDoIPick]

For some reason, I read your initial post as indicating you'd have to do all nights as a prepartner in the new job, looking over it again it looks like you just have to do your share. That, imo, makes this a no-brainer. In 3 years, hospital is going to be cutting pay by 20% each year and they'll be a line of mcHCA grads out the door waiting for a chance to work there.

Not sure this is how it actually works. If the cuts to reimbursement are as bad as projected, all will be affected.

Who do you think has more bargaining power with United Healthcare: the behemoth hospital system or the SDG?

Who do you think is more insulated: the hospital employed doc or the SDG doc (especially if the SDG takes a subsidy from the hospital)?

 

[turkeyjerky]

Not sure this is how it actually works. If the cuts to reimbursement are as bad as projected, all will be affected.

Who do you think has more bargaining power with United Healthcare: the behemoth hospital system or the SDG?

Who do you think is more insulated: the hospital employed doc or the SDG doc (especially if the SDG takes a subsidy from the hospital)?

I don't see emergency physician pay as being directly tied to reimbursement, it's more complicated than that. (What is reimbursement, anyway? A hospital gets paid a facility fee for every reimbursed visit, which is far in excess to the physician's professional fee. Without a doctor present they cannot charge it. So shouldn't hospital employed docs get paid more, since there's a bigger pot to dip into? Yet the opposite is typically the case)

I think in the current situation, 'market pay' is largely set by CMGs, and to a lesser extent large hospital systems, utilizing a complex formula of reimbursement, site productivity and, primarily, ability to recruit. Why does Usuck pay 140/hr in Denver? Why did attendings at my residency program make far less than I did after graduation, working at a hospital in the same system and same city, despite lower productivity and a worse payor mix? Why are SDGs able to pay prepartners far below 'market' yet recruit easily?

Ok, so hope the rest of this is logical.

Say the avg partner in a given SDG makes 500k a year or so, after overhead (90k in expenses). CMG or large hospital, because of shenanigans, gets 750k per doc per year in reimbursement. However they have higher overhead, so we'll say 600k after expenses. CMG needs their 20% profit margin, so they offer docs 450k/yr. Hospital-employed (HE) docs make 400k plus bennies.

Say, nationwide we see a 20% cut in reimbursement over the next 5 years and it remains flat thereafter.

Now SDG partner makes 380k/yr. CMG gets 600k per year in reimbursment/doc. However, they need to keep their same 150k/yr in overhead and their same 150k/yr in profit per doc. So they offer docs a flat 300k/yr. Hospital, which follows the market but isn't quite as cold-hearted, offers 325k plus bennies.

So, before we had a situation where paywise, SDG > CMG = HE . (Working conditions were SDG >> HE > CMG. ) Now, we have a situation where pay is SDG = HE > CMG. (working conditions now SDG > HE >> CMG).

Moreover, due the impending oversupply of emergency physicians we enter into an era of CMGs (who currently dominate the market, and will continue to do so. There's no reason to believe that these guys, who are both smarter and better supplied with information and insight into the market, won't continue to do so) reduce pay by 4% annually. So, after 5 years, that 300k becomes 255k. Hospital, who is less cold-hearted but also follows the market, reduces pay by 2.5% annually and pays 290k plus bennies.

So, in 10 years, we arrive to a situation where SDG pay >> HE > CMG. Plus, b/c of the lack of job security and continued midlevel expansion, relative working conditions are far superior at the SDG shop.

 

[Kryptocoin]

I don't see emergency physician pay as being directly tied to reimbursement, it's more complicated than that. (What is reimbursement, anyway? A hospital gets paid a facility fee for every reimbursed visit, which is far in excess to the physician's professional fee. Without a doctor present they cannot charge it. So shouldn't hospital employed docs get paid more, since there's a bigger pot to dip into? Yet the opposite is typically the case)

I think in the current situation, 'market pay' is largely set by CMGs, and to a lesser extent large hospital systems, utilizing a complex formula of reimbursement, site productivity and, primarily, ability to recruit. Why does Usuck pay 140/hr in Denver? Why did attendings at my residency program make far less than I did after graduation, working at a hospital in the same system and same city, despite lower productivity and a worse payor mix? Why are SDGs able to pay prepartners far below 'market' yet recruit easily?

Ok, so hope the rest of this is logical.

Say the avg partner in a given SDG makes 500k a year or so, after overhead (90k in expenses). CMG or large hospital, because of shenanigans, gets 750k per doc per year in reimbursement. However they have higher overhead, so we'll say 600k after expenses. CMG needs their 20% profit margin, so they offer docs 450k/yr. Hospital-employed (HE) docs make 400k plus bennies.

Say, nationwide we see a 20% cut in reimbursement over the next 5 years and it remains flat thereafter.

Now SDG partner makes 380k/yr. CMG gets 600k per year in reimbursment/doc. However, they need to keep their same 150k/yr in overhead and their same 150k/yr in profit per doc. So they offer docs a flat 300k/yr. Hospital, which follows the market but isn't quite as cold-hearted, offers 325k plus bennies.

So, before we had a situation where paywise, SDG > CMG = HE . (Working conditions were SDG >> HE > CMG. ) Now, we have a situation where pay is SDG = HE > CMG. (working conditions now SDG > HE >> CMG).

Moreover, due the impending oversupply of emergency physicians we enter into an era of CMGs (who currently dominate the market, and will continue to do so. There's no reason to believe that these guys, who are both smarter and better supplied with information and insight into the market, won't continue to do so) reduce pay by 4% annually. So, after 5 years, that 300k becomes 255k. Hospital, who is less cold-hearted but also follows the market, reduces pay by 2.5% annually and pays 290k plus bennies.

So, in 10 years, we arrive to a situation where SDG pay >> HE > CMG. Plus, b/c of the lack of job security and continued midlevel expansion, relative working conditions are far superior at the SDG shop.

I think the new trend in the future will be hospitals employing docs as 1099 or W2 and then using CMGs for scheduling and billing. Gives the hospitals more control and improves their margins.

 

[namethatsmell]

-Much more control over things (when partner). I don't know what this really even means. Hospitals still own you. SDGs have very little control over anything other than scheduling. The metrics, pt sats does not go away.

Listen to this man.

All groups, including SDGs, are perpetually one c-suite tantrum (or personnel change) away from losing their contract. And for that one reason, there is no such thing as having significant control in EM (outside owning a FSED).

 

[NYEMMED]

Listen to this man.

All groups, including SDGs, are perpetually one c-suite tantrum (or personnel change) away from losing their contract. And for that one reason, there is no such thing as having significant control in EM (outside owning a FSED).

Very true.
And if the SDG only has a contract at the same system, that’s the end of the SDG unfortunately.

CMGs are hurting, I imagine SDGs are too

 

[WhatJobDoIPick]

Update:

Working for a bit now with the new SDG.

What a breath of fresh air.

Things actually work. People actually care.

Sure there's issues, but the difference is there's people actively working on them.

I'm really glad I jumped ship.

Btw, none of those leadership clowns at last gig even said bye to me. What idiots.

 

[EctopicFetus]

Update:

Working for a bit now with the new SDG.

What a breath of fresh air.

Things actually work. People actually care.

Sure there's issues, but the difference is there's people actively working on them.

I'm really glad I jumped ship.

Btw, none of those leadership clowns at last gig even said bye to me. What idiots.

Thanks for the update. outside of a few parasitic SDGs hard to imagine a scenario where they SDG avenue isnt better. I did review a job opportunity for someone. SDG in a flyover city. Pay was atrocious. I told him unless the recruiter didnt understand pay per hour vs annual he would likely never recover. It’s a city with Vituity… vituity is near 300/hr, before he made partner he would make under 150/hr avg over 3 years. They wanted 1700+ hours.. the math there is insane and with market returns i said unless the sdg really makes way way more per hour he would never make up this 3 year difference.

The crap SDG jobs exist, there are way way fewer of them now. Most sold out before due to greed.

 

[emergentmd]

The crap SDG jobs exist, there are way way fewer of them now. Most sold out before due to greed.

You can call it greed, I call it good business sense. The writing was and is on the wall. There are some SDGs that will do well and continue to exist. But you are playing russian roulette every year the SDG is in existence. Unless you own something, you are still are employed by someone. SDG ownership owns nothing but a promise

 

[skougess]

You can call it greed, I call it good business sense. The writing was and is on the wall. There are some SDGs that will do well and continue to exist. But you are playing russian roulette every year the SDG is in existence. Unless you own something, you are still are employed by someone. SDG ownership owns nothing but a promise

SDGs generally end up being a good deal (I am in one myself), but it’s insanity in the business world to hitch your entire business to one customer, which is what most SDGs do. Gotta keep that perspective.

 

[EctopicFetus]

You can call it greed, I call it good business sense. The writing was and is on the wall. There are some SDGs that will do well and continue to exist. But you are playing russian roulette every year the SDG is in existence. Unless you own something, you are still are employed by someone. SDG ownership owns nothing but a promise

I usually see eye to eye with you but practically what you are selling is the labor of future docs. The ones who do the best are those near retirement. They reaped the rewards of an SDG and then sell out last minute to capture the profits of those coming after them.

I get business, i understand this perspective but selling an ED contract is also just selling the future services of that ED.

 

[Restart13]

SDGs generally end up being a good deal (I am in one myself), but it’s insanity in the business world to hitch your entire business to one customer, which is what most SDGs do. Gotta keep that perspective.

Our SDG unfortunately is tied to a major player healthcare system in a midsize city. recently over the last year we have faced cuts with stipends and have had to make some tough choices. problem is we are overly dependent on them. doubt they are as much dependent on us.

 

[emergentmd]

I usually see eye to eye with you but practically what you are selling is the labor of future docs. The ones who do the best are those near retirement. They reaped the rewards of an SDG and then sell out last minute to capture the profits of those coming after them.

I get business, i understand this perspective but selling an ED contract is also just selling the future services of that ED.

You are looking it wrong. Many sale is not always 100% voluntary. Our SDG sold out because the choice was either sell/be nice for 2 yrs or have it taken away. The other end of the spectrum is someone selling completely voluntarily. Many other sales are somewhere in between when you see the writing on the wall. Either sell when the price is still good or risk having it take away for nothing at any moment.

It is easy to say not to sell and put docs in subservient labor but the mathematics becomes much more difficult when you see the inevitable takeover.

Our FSER was offered 20x EBIDTA by a large corporation and our group refused because we know no one can take over our business because we actually own something.

 

[EctopicFetus]

You are looking it wrong. Many sale is not always 100% voluntary. Our SDG sold out because the choice was either sell/be nice for 2 yrs or have it taken away. The other end of the spectrum is someone selling completely voluntarily. Many other sales are somewhere in between when you see the writing on the wall. Either sell when the price is still good or risk having it take away for nothing at any moment.

It is easy to say not to sell and put docs in subservient labor but the mathematics becomes much more difficult when you see the inevitable takeover.

Our FSER was offered 20x EBIDTA by a large corporation and our group refused because we know no one can take over our business because we actually own something.

I do understand the “inevitable” argument. I have seen and consulted for groups that went through that. The math there is very different.

I’ll also point out the market has shriveled up.. there is that new CMG growing by buying stuff up but the multiples are gone.

 

[Meyer-Overton]

second one

 

[emergentmd]

I do understand the “inevitable” argument. I have seen and consulted for groups that went through that. The math there is very different.

I’ll also point out the market has shriveled up.. there is that new CMG growing by buying stuff up but the multiples are gone.

The market definitely has softened. CMGs are smart and understand that there is no reason to overpay for SDGs unless there is a unique situation.

The 20x Ebidta was less than 6 months ago. No way a SDG would get this multiple. When our SDG was taken over years ago, I believe our EBIDTA multiple was 5x EBIDTA which is a good deal for not having any tangible asset.

 

[EctopicFetus]

The market definitely has softened. CMGs are smart and understand that there is no reason to overpay for SDGs unless there is a unique situation.

The 20x Ebidta was less than 6 months ago. No way a SDG would get this multiple. When our SDG was taken over years ago, I believe our EBIDTA multiple was 5x EBIDTA which is a good deal for not having any tangible asset.

Peak of market was 12-13x for sdgs. 5x seems low but it all depends on a ton of factors. Undoubtedly the price one would pay for a solid FSED is more. 20x is crazy but i assume that means you have a lot of growth in front of you. Your forward looking EBITDA would not be at 20x. Frankly, if it is for you guys you made a mistake not selling but im confident it isnt.more likely the future profits are higher for you and the people who wanted to buy it from you were likely paying a multiple of under 10 on future profits not including whatever they would pay for the real estate, equipment etc.

 

[emergentmd]

5x was because CMG knew we had to sell. That 5x was to keep docs for 2 yrs and not create medical staff troubles. They could have had our group for 0x but forced by hospital to give us something. So ended up somewhere in the middle.

With FSER and actually owning something, it gives you the utmost leverage over just making economic sense.

 

[Restart13]

For a large SDG with ancillary services would a 5x EBIDITA for partnership buy-in be worth it? Almost seems like private equity multipliers. Half of it paid in sweat equity over 4 years