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Which Job?

Discussion in 'Anesthesiology' started by Unemployeddoc, Oct 6, 2017.

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  1. Unemployeddoc

    Unemployeddoc

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    Throw away account for anonymity.

    Representative new grad job offers and the state of the current market in the southwest...

    Job 1: Hospital employee. physician only. W2. ~350K, no OB, moderate call, probably 55-60 hrs/week. Super competitive retirement package with 401k/457f, profit sharing. loan repayment, stipend, and sign on bonus worth another ~200k. Level 2 trauma center and surg center.

    Job 2: True private practice track small community hospital. physician only. 3 year track, no buy-in. 300k till partner. "they don't hire people that don't make partner". Ceiling ~600k after full partner. Switch to 1099 as full partner. 401k match but no other bells and whistles. Strong group leaders with "no plan to sell" and contract with hospital for past 30+ years. No trauma. q4 call from home but a lot of OB call backs. CRNA presence but cover own cases but apparently "can consult you" on difficult cases...

    Job 3: Large AMC. W2. physician only (for now). Level 2 trauma. 475-500k a year. competitive retirement package. 25k sign on bonus. Home call except OB x2 per month in house.

    Everything else is equal in terms of location, quality of life, cost of living, schools, tail coverage, etc..

    New grad with an @$$ load of debt, no money set away looking for an Aug 1st start. Stipend and retirement package are enticing. Don't really know about shooting for the stars with private practice group as that seems to be the 'holy grail'. Curious if those that have been around the block have any advice as to which job they would choose with a gun to their head and why. Any thing worth negotiating? Has to be one of these three jobs...

    Thanks!
     
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  3. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    In the future just PM me and I can post something like this anonymously.
     
  4. Man o War

    Man o War 2+ Year Member

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    Private practice does not necessarily equal holy grail!
    I'll be interested to see what others say, but the collaborative model that you describe in the private practice job is absolutely fraught with issues IMO. I can't see myself ever entering into a practice like that.
    The AMC job looks the most attractive on the surface. I'd need to see the specifics though. These AMCs are notorious for understaffing docs to save money and working the rest to death. Do you get post call days off? Do you get a differential in pay for late running rooms or will they work you to death all day every day for the same pay? What is the real call back rate from home at night?
     
  5. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    I'm confused why you say no buy-in for job 2. Sounds like a 900k buy-in to me.
     
  6. Twiggidy

    Twiggidy ASA Member 2+ Year Member

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    Personally:
    I'd probably take Job 1 and sleep in my bed everynight, but that's just me.....if it's q4 from home with alot of OB call backs, the it's basically Q4 in house.

    and like Salty said...they may say no buy-in but you're basically buying in for 900k if you do that math
     
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  7. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor Classifieds Approved 10+ Year Member

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    the opposite pole
    To me, Job 1 looks like a long-term one. Job 2 is guaranteed burnout, sooner or later. Q4 call with busy OB, even from home, is too much, unless you have a ton of vacation. Three-year track is too long. Job 3 is an iceberg, you just don't see it yet. They will work you raw for that money, no doubts in my mind.

    Also, consider what you end up post-tax in all cases. A job with a smaller post-tax salary but with a lot of pre-tax benefits might be better overall, not only on an hourly net income basis. If I could budget for any of the 3 jobs and still save some money, I would take the one that fits me best and makes me the happiest, not the one with the biggest paycheck etc.
     
  8. nimbus

    nimbus Member 10+ Year Member

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    The job 3(500k w2) is the same as job 2 (600k 1099) but with no buyin.

    For job 1, what proportion of the 200k 1st year benefit package is retirement, profit sharing, and how much is signing bonus? A large signing bonus is not good if you don't get it in subsequent years. It would be better if a large part is profit sharing that will recur year after year. How much is 2nd year income? 350k for 60hr week is not good, even in low pay areas.

    AMC job looks best to these eyes.
     
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  9. Unemployeddoc

    Unemployeddoc

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    already incredibly helpful. Thanks. I value all your input.

    The amc guys work hard no doubt about that.

    I’m ignorant enough not to have seen the 3 year track as a 900k buy in especially the way it was sold to me.

    Starting to see red flags that I missed thanks to you all!
     
  10. Unemployeddoc

    Unemployeddoc

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    Job 1 is 25k sign on. In terms of profit sharing it has consistently been around 30k year for past eight years. They also offer a retention bonus every year after year 3 of 10% of salary. They seem to consistently make 350-400 every year.
     
  11. Hoya11

    Hoya11 Senior Member 10+ Year Member

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    job 1: sounds like a safe choice all around, moderate call, moderate income.

    job 2: CRNA working on their own and consulting you?.. very sketchy. also q4 call for the rest of your life? no thanks.

    job 3: great income but i agree they would have to work you to death for this. i would eliminate this option.

    If these are your only options, I would take job 1.

    My advice: look for a job like job 2 but a little bit bigger practice so the call burden is easier and no sketchy solo crnas (unless thats a common thing that im not aware of).
     
  12. GravelRider

    GravelRider SDN Lifetime Donor Lifetime Donor Gold Donor Classifieds Approved 2+ Year Member

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    Job 1: The benefits are worth 200k every year? No OB may be a plus or minus depending on your preference. In-house call?

    Job 2: The collaborative model is a non-starter for me. Q4 call is a lot, but if the in-between days are fairly light then it may not be so bad.

    Job 3: That's a higher paying AMC job, so I'd be suspicious. It might be the best option, but I would try to get a better idea of workload and environment. Do they have high physician turnover?


    Based on limited information, I would be leaning towards job 1.
     
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  13. Maverikk

    Maverikk ASA Member 2+ Year Member

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    Whenever an AMC says it's moving to supervision from an all MD practice, especially if they've bought the practice in the last 5 years, expect to be supervising 4 rooms for the rest of your career within 5 years
     
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  14. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 10+ Year Member

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    Job 1 and 3 would be relatively easy for me to walk away from. With job 2 I'd look at it as more of a long term home. Better make sure it's exactly what you want before committing. If you feel like they are trying to "sell" you on something that's a red flag all by itself.
     
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  15. Ezekiel2517

    Ezekiel2517 Anesthesiologist Physician 10+ Year Member

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    This is like having a refrigerator filled with food but nothing I want to eat.
     
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  16. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

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    That's this job market in general FWIW. It's not what you want but what you can tolerate that defines this job market. Compared to the East Coast of the USA these jobs are in general superior to what I see posted for a new grad.

    So, using your analogy on the East Coast the fridge is just half-filled with junk food.
     
  17. Shimmy8

    Shimmy8 ASA Member 5+ Year Member

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    Agreed.

    These are higher paying than East Coast for sure.

    What sized cities are these jobs in? Based on pay I'm guessing they're in relatively small-medium cities that wouldn't be considered "desirable" overall?
     
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  18. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor Classifieds Approved 10+ Year Member

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    Job 1 sounds like the safe choice. Read the fine print on the 457f. A lot of them are crap. Also sign on bonus pay back terms in case you leave early.
    Job 2 high risk high reward type strategy. Covering the CRNAs collaboratively is something you have to decide whether or not you can make peace with.

    You don't mention case mix. If a new grad I would want to do almost everything in my first position so my skills don't atrophy.
    Look real hard at group leadership structure and your gut feeling about the docs in the groups. Give lots of weight to whether or not you feel the chemistry is particularly good or bad.
     
  19. Shimmy8

    Shimmy8 ASA Member 5+ Year Member

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    You also need to figure out details/hours of that AMC job #3. I work for I guess what's considered a small/regional AMC and I'm very happy overall. Great benefits.

    Granted I had friends in my current group already and I'm in an incredibly fun city, which was important to me.

    I turned a true PP job down because I didn't like leadership/fit/chemistry.

    I'd also talk to folks about the Level 2 trauma...one of facilities I work at is a level 2 but based on the growing city, area of town, and proximity to interstate it's basically a level 1. I don't mind it coming right out but I'd be sure to ask.
     
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  20. Unemployeddoc

    Unemployeddoc

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    Sep 29, 2017
    I checked out seven jobs. 3pp 2 amc and 2 hospital employed. These three were the best of the bunch in my opinion.

    They are all 100-200k size cities, but at least two hours from a major city 1-2 mil +.

    Job 1 and 3 I can do everything but hearts. Job 2 is a low acuity community hospital with not a lot of flashy cases.

    I’m locked in for 3 years in job 1 or I payback all my benefits.

    This is my experience with the market. Apparently it’s a good time to be looking for a job or so I’m told. Guess I just had to pick something in the fridge I can stomach eating for a couple years.
     
  21. bigdan

    bigdan SDN Donor 10+ Year Member

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    If you've got these 3 options as your "final choices", I'd probably take #1.

    I saw you said you have a bunch of debt - if they're offering loan repayment, that's a tax free bonus to your yearly income. Remember that 457s are not protected from creditors (God forbid something go wrong with the hospital's finances), and that non-gov't 457s are difficult to transfer, and you may have to take the amount as income if you leave the job and cannot workout a transfer of the 457. Job #1 is also hands-on work, right? In one man's opinion (mine!), that's a big plus. No OB is also a "stipend" in my mind :). Also - allow me to put in a plug for living frugally and seeking a loan refinance option to get you to the minimal interest rate to pay those bad boys off.

    Job #2 has an unacceptably high buy-in, and the fact they say "No buy-in" to your face is concerning. 1099s do allow considerable tax flexibility, so to make $600k on a 1099 does sound appealing. The kickers to me are 1. it doesn't sound like Job #2 owns/controls the nurses (you listed as "physician only" with a "CRNA presence") - that sounds like a major pain in the ass to me - and 2. q4 home call with frequent call back. Do you have to stay in-house with epidural running, or if the Ob is "concerned about a tracing"? $300k flat x 3y + "home call" but you're always called back = sham offer. Last, I'd prolly test the waters and ask if they'd guarantee you some form of parachute if they sell to an AMC during your 3 non-partner years.

    Job #3 is one to approach with great caution. A friend took a job with a nationwide AMC in City A, only to be told (after securing housing and beginning his move to said city) that City B REEEALLLLY need help, so he would be working in City B if he wanted to keep his job. On top of this, he's now getting crushed 50-55/hrs week but ALWAYS 4 rooms, for like $350k. I know you're MD only now, and getting paid more than my homeboy, but the math that works for AMCs is to 1. get insurance companies to pay more than they were before for anesthesia services, and 2. run lean (with staffing) and mean (to employees). *I understand there are exceptions - I hope this is one of them - but buyer beware*.

    Good luck
     
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  22. AdmiralChz

    AdmiralChz ASA Member 7+ Year Member

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    Talking about Job 2 - right before I graduated residency we had a new faculty member who left a “collaborative” model similar to described above. He was sued twice in five years when cases went south (you'd better bet you're the one on the hook, even if you have minimal connection to the case). The admin eventually revolted and demanded more physician oversight given multiple sentinel events over 10 years, so a local PP group took over with a 3:1 ratio (and the anesthesiologist came back to academics). Basically you'd need to demand a very high salary to (partially) offset the high risk of being the fall guy for a given practice model. I'm not sure Job 2 is exactly what I am describing, but something to consider and I know others on this forum work in such practice models - essentially a "medical director" role with independent CRNAs running around.

    I agree with the others that you should look closely at the long game for the other two jobs, since no one here is really recommending Job 2.
     
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  23. Man o War

    Man o War 2+ Year Member

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    This. Exactly this. This is kind of a newer practice model and it's scary as hell. All that nurse has to do is document their consult with you and I'm sure you're on the hook. You have no control over the quality of nurse they hire, most of them are pretty scary when things are anything beyond straight forward, so there's no way I want anything to do with what they do and I'm not consulting with them. If you're so big and bad that you don't need supervision, you shouldn't have to ask me anything.
    For that AMC job, you need everything in writing. Your hourly rate past 5:00 (or whatever threshold you set), your hourly rate for working post call days, your rate for taking any call beyond the agreed upon amount. Get everything in writing! If they aren't willing to do that, well, there's your answer.
     
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  24. ryanjmy

    ryanjmy 7+ Year Member

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    You have options not great options but that gives you negotiating power. For one and three you could possibly negotiate for more money, especially #1. I'd make sure they knew you are considering 2 offers for significantly more $$$. For job 2 the main concern is never making partner. It'll be harder to get more money out of a pp group but the terms of making partner could be modified. The best might be to ask for full partner after 1 year with salary set at 300 for 2 more years. That would protect you from missing out on a buyout or wasting 2 more years without making partner.
     
  25. Robotic Wis-Hipple

    Robotic Wis-Hipple ASA Member

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    3 years to partner in this climate is a no go imo. Unless significant in writing protections (prorated buyout, partner after year 1 with continued lower salary etc)
     
  26. nimbus

    nimbus Member 10+ Year Member

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    Yes to me this job looks like a ripoff. The partner income is basically no different than the AMC job but you're at 300k for 3 years. And the case mix does not seem ideal for a new grad. And you have to deal with CRNAs. The partner income is also artificially inflated because they are ripping off their new associates. How much would the practice generate if everyone was a partner? What is the ratio of partners to non-partners? It's not a good practice if you need to feed on your young in order to make a decent income.

    Job 1 is working 55-60 hrs/week for 350-400k. How much harder could they possibly be working at Job 3 for 475-500k?

    To me it seems like a no brainer. Job 3 looks pretty good. MD only, inhouse call only 2x/month. Decent income. Just make sure you sign just for that specific site.
     
    Last edited: Oct 7, 2017
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  27. FFP

    FFP Grunt, cog, body, pompous ass Gold Donor Classifieds Approved 10+ Year Member

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    Typical (understaffed) AMC job: you are on O/N call every 4th day. When you are not on call, you leave at 7-8. When you are on call, you do elective cases till late in the night and tons of OB, plus trauma. Likey?

    Typical level 2 trauma community hospital job (especially without OB, especially if there is a better trauma center around): you do urgent/emergent cases till 9 pm. You go to bed. 3 nights out of 4 you sleep most of the night. When not on call, you leave at 3. You have 5-6 overnight calls/month, the more docs the fewer.
     
    Last edited: Oct 7, 2017
  28. nimbus

    nimbus Member 10+ Year Member

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    We are all working under assumptions. The OP needs to collect and provide more job specific information. Hopefully he has an opportunity to talk to people at the different practices before he makes a decision.

    I know for a fact that not all AMC hospitals do "elective cases till late in the night". Within the same AMC, there are usually wide variations site to site.
     
    Last edited: Oct 7, 2017
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