Where do you see yourself...?

[ldsrmdude]

As I've been looking at programs that I want to do clerkships at, I have been thinking a bit more about my long-term goals. I was just curious where everyone sees themselves after residency. Do you want to open up shop on your own, join an orthopedic group, a multi-specialty group, etc? I thought about making this a poll, but there are way more options that I can think of.

Personally, I want to get involved in academics, and teach. Ideally I would like to be faculty at one of the podiatry schools, see patients at a clinic, and do research; sort of a little bit of everything.

So, what are you interested in?

---

Members don't see this ad.

 

[g squared 23]

I want to join an orthopedic group, because they pay a lot better than private practice docs hiring associates (private practice is dying). And I don't want to have to deal with billing/coding and fighting with insurance companies. No thank you. I would like to be involved in residency training, but not asking stupid pimping questions; just molding future surgeons in my own image and watching them mature into great podiatrists.

I only want to work 4 days a week during the fall so that I can hunt or do whatever I want on my days off. I'll work 12 hours the other days if I have to, and even Saturdays in the off-season.

I want to go back to my alma mater and give a few lectures to students. Then inform them as honestly and realistically as I can about exactly what the next few years of their professional life is going to be like. They'll want answers, and I'll give them without any sugar coating or bullsh*t. I'll invite first years to shadow me during their last summer off.

 

[Feli]

I want to join an orthopedic group, because they pay a lot better than private practice docs hiring associates (private practice is dying). And I don't want to have to deal with billing/coding and fighting with insurance companies...

Not to burst your bubble here, but ortho practices ARE private practices. So are general, vasc, plastics, etc surgery groups. So are family practice groups, int med, OB, etc etc. So are multispecialty groups. They're all small - sometimes medium sized - businesses. They all have billers, coders, and overhead/staffing issues. If you think it's a good thing to not have to face those realities, then stay at the level of associate or junior partner... and don't ever go for senior partnership or a controlling interest in the company.

If you start or buy/partner into a pod group that's well run, you can make just as much - if not more - than you can working/partnering in an ortho group. The reason is that you will have a greater percentage of partnership... potentially 100% if you start your practice or buy out a retiring solo office DPM. Try to find me a DPM who is the main holder or owner of an ortho group lol. Even if you were indepently wealthy and could meet the rediculously high prices for a lion's share (huge IF), chances are that you'd get an answer like "not for sale" or "sorry, I'll only sell X%" (X= one percent less than the majority owner). The startup costs or parnership buy in/out will usually be significantly less expensive in a pod group, and they are within reach. As you get more experience, you will see that the DPMs who know what they're doing certainly aren't starving.

The only real obvious advantage to ortho groups is that they face little or no discrimination in gaining referrals such as ER follow ups and other area docs. They will be very busy and profitable if they have halfway decent business sense. You will be discriminated against in a pod group, so you have to be a bit more astute and active in eductating PCPs, networking with other area specialists, marketing, etc in order help the patients understand the breadth of your skills and garner referrals from other docs who may have antiquated views of DPM capabilities.

If you go the pod route, I honestly think you have higher top end due to potential for higher ownership %, especially if DPMs underbid one another on the ortho group job offerings. You can certainly do well in either, but I think too many residency grads are starstruck by the initial salary offerings and will do whatever it takes to get that. You have to look 5, 10, etc yrs down the line and not just at initial earnings. It all depends on whether your long term goals are to collect what you have earned or to pay management fees to, take call for, etc a senior partner or two who had the stones to start the practice or buy a controlling interest in it. At then end of the day, it's business, and you are either the hammer or the anvil.

...If you want to teach and be involved with residency, then maybe working for a pod school or hospital system is an option worth looking into. You will get a good comfortable salary with benefits, but your upside/incentive is usually significantly limited compared to private practice since hospital or univ employees are, in essence, high paid associates. Also, your say in staffing/billing/business etc decisions is limited... but your responsibilities in those areas is also low, so that's a good thing or a bad thing - depending on how you view it.

 

[g squared 23]

^I'll agree that in the long run, private pod practice might be the way to go, but certainly not in the short term. The problem with a private practice pod hiring an associate (and please correct me if I am mistaken because this is just my understanding) is that the podiatrist is "sharing" his patient load with you and you are both "dipping into the same pot" until the new associate can build up his own patient base (which the hiring doc then "owns" until the associate buys in as partner and gets a bigger slice of the pie).


With an ortho group, you are the F&A guy who gets all the cases and therefore a bigger workload, which can potentially make you a lot more money if your pay is incentive based. And hopefully the group is big enough that they have hired someone to do the coding/billing so that I don't have to deal with it. You might have to train them initially (and a bit here and there later on) on podiatry specific cases and billing, but eventually you don't have to worry about it (as long as the said hired hand is competent).

 

[g squared 23]

I don't know how exactly it would work, but hopefully I wouldn't have to be employed at a hospital or pod school. I would rather simply bring my interesting cases and work with the residents and my fee would be a thank you note at the end of the year. I'd rather not be too extensively involved like a director or faculty member as I wouldn't want to be married to the residents: I would prefer to work with the ones that I liked the most and I felt learned from me the best. As a residency director, you don't have a choice and have to train them all at some point.

 

[g squared 23]

Feli, you do bring up a great point. A lot of ortho groups won't let pods buy in as a senior partner and they end up working as an employee for the practice. The initial salary is decent enough to attract new graduates, but doesn't ascend enough to keep the new hire on for more than a year or two. We have a group in town that supposedly does just that and ends up hiring a new podiatrist every year or two. They don't care because they know more cheap labor (new graduates) will follow.

I obviously would only sign on with a group with the intention of one day buying in as a senior partner. I'm going to ask this on day one and if I don't get the answer that I'm looking for, then obvioiusly I would look elsewhere.

 

[g squared 23]

Your thinking makes sense, but that's just not how things usually work.

Ortho groups are still "dipping into the same pot" to find patients for their junior associates who are fresh out of residency or new to the area. Do you think the senior/middle/junior partner and even other associate gen orthos don't know how to do ankle fractures? Ankle fusion? Jones fractures? Achilles rupture? They all know how to fix those. Some will even have been well trained, and maybe like, to do triples, flatfoot, etc etc.

Keep in mind that whether it's an ortho group, pod group, or whatever it is, the referrals will mostly come in the name of the senior and well known partners. They are the guys whose name is on the sign, they are the ones who are well known in the area, and it's their skill that built and grew the office. It's then up to them to "divy up" the referral and ER f/u patients among the providers in the group. You would be suprised how many DPMs in ortho groups don't even like to give their ankle fracture ER follow-ups to their DPM hiree (well, maybe if they have low/no insurance?).

Anywhere you go, associateship or junior partnership is just that: you are the low man. In a pod group, you have a chance to become, or even start as, the higher (even highest) man for a much cheaper price. You also have a reasonable shot at getting the group's most complex surgical cases fairly early since DPMs who trained years ago are less likely to have had the residency length and volume today's young guns get. That is the bottom line here.

If you go the associate route with the intent of partnering your way up - in either pod or ortho, then just make sure the group has a real need for a new doc. If they do have patients lined up out the door, then maybe they'll turf more your way. If they are hiring just to hire, then that "dipping pot," might be a bit too thin, and the low man is likely to not get many good cases or well insured patients. In the end, you definitely want to get legal advice on any contract, but it's often said that "a contract is only as good as the morals of the people signing it." Analyze and scrutinize any private group practice - or even hospital/univ system - that you are thinking of getting into. GL

Good advice. Thanks for the insight.

 

[Feli]

^I'll agree that in the long run, private pod practice might be the way to go, but certainly not in the short term. The problem with a private practice pod hiring an associate (and please correct me if I am mistaken because this is just my understanding) is that the podiatrist is "sharing" his patient load with you and you are both "dipping into the same pot" until the new associate can build up his own patient base (which the hiring doc then "owns" until the associate buys in as partner and gets a bigger slice of the pie).

With an ortho group, you are the F&A guy who gets all the cases and therefore a bigger workload, which can potentially make you a lot more money if your pay is incentive based. And hopefully the group is big enough that they have hired someone to do the coding/billing so that I don't have to deal with it. You might have to train them initially (and a bit here and there later on) on podiatry specific cases and billing, but eventually you don't have to worry about it (as long as the said hired hand is competent).

Your thinking makes sense, but that's just not how things usually work.

Ortho groups are still "dipping into the same pot" to find patients for their junior associates who are fresh out of residency or new to the area. Do you think the senior/middle/junior partner and even other associate gen orthos don't know how to do ankle fractures? Ankle fusion? Jones fractures? Achilles rupture? They all know how to fix those. Some gen orthos, peds, trama, sports, etc will even have been well trained, and maybe like, to do triples, ankle scopes, flatfoot, calcs, met adductus, lisfranc, etc etc. It doesn't matter if you're "better" at those cases or not; it matters that those cases pay... and other more senior partners may want to "share" those type of referrals - or snipe them altogether - for that reasoning. What if it's a big ortho group that already has a guy who is a good sized % owner (more than you are ever likely to afford) with F&A interest... maybe fellowship training. The plot thickens... will you just be getting poorly insured bunion pts, diabetic wound pts, and only seeing the "good F&A cases" when certain other partners are out of town?

Keep in mind that whether it's an ortho group, pod group, or whatever it is, the referrals will mostly come in the name of the senior and well known partners. They are the guys whose name is on the sign, they are the ones who are well known in the area, and it's their skill that built and grew the office. It's then up to them to "divy up" the referral and ER f/u patients among the providers in the group. You would be suprised how many ortho groups are nice enough to hire a DPM but don't give their ankle fracture ER follow-ups to that DPM hiree (well, maybe if the pt has low/no insurance?). Also keep in mind that the DPM in the ortho group won't usually take much/any call since call has to cover everything yet we are only limited scope, so there's no guarantee you'll gain fx cases on call either.

Anywhere you go, associateship or junior partnership is just that: you are the low man on the totem pole. In a pod group, you have a chance to become, or even start as, the higher (even highest) man for a much cheaper price. You want to be one of the guys with your name on the sign who determines which new pts/cases you see and which get passed on down the line to lower partners or associates. In pod, you also might have a reasonable shot at getting the group's most complex surgical cases fairly early in your career since DPMs who trained years ago are less likely to have had the residency length and volume today's young guns get. That is the bottom line here.

If you go the associate route with the intent of partnering your way up - in either pod or ortho, then just make sure the group has a real need for a new doc. If they do have patients lined up out the door, then maybe they'll turf more your way. If they are hiring just to hire, then that "dipping pot," might be a bit too thin, and the low man is likely to not get many good cases or well insured patients. If an ortho group of 3 docs is so busy with total joints, ACLs, rotators, etc that their foot and ankle stuff is turning into an afterthought, then jump on that (assuming they make a good offer). Likewise, a pod group with 3 docs who have minimal/no surgical training yet are fantastic businessmen with high pt volume is also probably a good offer (again, if the salary and buy-in are reasonable). In the end, you definitely want to get legal advice on any contract, but it's often said that "a contract is only as good as the morals of the people signing it." Analyze and scrutinize any private group practice - or even hospital/univ system - that you are thinking of getting into. GL

 

[Feli]

... The initial salary is decent enough to attract new graduates, but doesn't ascend enough to keep the new hire on for more than a year or two. We have a group in town that supposedly does just that and ends up hiring a new podiatrist every year or two. They don't care because they know more cheap labor (new graduates) will follow.

I obviously would only sign on with a group with the intention of one day buying in as a senior partner. I'm going to ask this on day one and if I don't get the answer that I'm looking for, then obvioiusly I would look elsewhere.

This is good insight. No group hires a new associate or juinior partner thinking "gee, I wonder how we can quickly make this guy rich and increase his ownership in our practice." It's actually quite the opposite, and the closed door meeting probably goes a lot more, "let's see... if we hire this guy, how can his productivity help to increase our income?"

$100k or 150k off the bat will seem all spectacular when you are probably used to PMS or resident living standards, but you have to look down the road, consider all the hard work you have put in, and try not to limit yourself. Chances are that few things would make that "dream job" turn into a nightmare faster than being there 3yrs later with many more pts/responsibilities yet only a 5 or 10% bump in that salary. Probably even more frustrating, what if the the buy amount is totally reduculous... or still no buy in opportunity even offered?

Consider right away what are the buy in terms and timeline? Is it a set amount at the time you join the group... or based on a dynamic practice valuation system of future gross/net? Will your buy-in be deducted from each paycheck or a lump sum whenever you decide... pre or post tax income... probably a mix? What's the productivity bonus... first year... future years? Benefits? Termination with/without cause details and non-compete stipulations? Etc? Just because the group's senior partners are driving nice cars, taking fancy vacations, and doing great cases, that sure doesn't mean you will be enjoying the same things as soon as the ink's dry on your contract. They usually didn't reach their success by overpaying new hire docs, giving them the good cases with good insurance, or giving away their practice ownership cheaply.