Which would you pick?

[cyanide12345678]

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Confused as hell between three options to sign for my first contract. Keep going back and forth. I'd very easily pick the SDG if I planned on staying in this area for a long time, but I only plan on staying for a couple of yrs only.

Which would you pick and why?

1) 200/hr, 30k sign on over 1 yr, Excellent staffing 1.6-1.7 PPH, SDG, Partnership after 1 year (roughly extra 5-14 per hour per share owned. Books are zeroed out every 6 months), no buy in, smaller hospitals with lower acuity. Driving distance ~ 35-50 minutes. Superior benefits than the other two.

2) 200/hr days, 215/hr nights, 100k sign on over 2 yrs, 2.1-2.2 pph (but co signing around 3 pph charts), significant MLP coverage, MLPs see all acuity levels, 40-50% of pts seen by MLPs, increased liability because you co sign their charts too, medium acuity, CMG, driving distance 5 minutes. Usual benefits for any large CMG group.

3) 215/hr, 25k sign on over 2 yrs, CMG group, Residency program, 2.5-2.6 PPH with residents. 401k matching (not in other two), + usual benefits. Medium acuity. Driving distance 25 minutes.

This whole process has been confusing. Anytime I make a decision, another group tries to sweeten their offer and makes me confused all over again -_-

 

[miacomet]

Definitely the first, unless you plan on doing nights or are obsessed with residents. Second choice would be the third. If someone is offering a 100k sign-on, it's a crap job and they need to keep people on the hook, and that is a crazy level of ML signing.

 

[VA Hopeful Dr]

Definitely the first, unless you plan on doing nights or are obsessed with residents. Second choice would be the third. If someone is offering a 100k sign-on, it's a crap job and they need to keep people on the hook, and that is a crazy level of ML signing.

No kidding. I'm not EM so can't comment on much, but half of all patients at any acuity seen by midlevels? Hard pass from any specialty.

And I was offered a 100k signing bonus for an FM job. Middle of nowhere, something like 80% medicare/caid. No one pays that kind of bonus for a good job.

 

[Janders]

1 or 3 based on your desire to teach residents, acuity, ability to work in a smaller more austere environment... compensation sounds close enough.

 

[Groove]

Confused as hell between three options to sign for my first contract. Keep going back and forth. I'd very easily pick the SDG if I planned on staying in this area for a long time, but I only plan on staying for a couple of yrs only.

Which would you pick and why?

1) 200/hr, 30k sign on over 1 yr, Excellent staffing 1.6-1.7 PPH, SDG, Partnership after 1 year (roughly extra 5-14 per hour per share owned. Books are zeroed out every 6 months), no buy in, smaller hospitals with lower acuity. Driving distance ~ 35-50 minutes. Superior benefits than the other two.

2) 200/hr days, 215/hr nights, 100k sign on over 2 yrs, 2.1-2.2 pph (but co signing around 3 pph charts), significant MLP coverage, MLPs see all acuity levels, 40-50% of pts seen by MLPs, increased liability because you co sign their charts too, medium acuity, CMG, driving distance 5 minutes. Usual benefits for any large CMG group.

3) 215/hr, 25k sign on over 2 yrs, CMG group, Residency program, 2.5-2.6 PPH with residents. 401k matching (not in other two), + usual benefits. Medium acuity. Driving distance 25 minutes.

This whole process has been confusing. Anytime I make a decision, another group tries to sweeten their offer and makes me confused all over again -_-

Are you sure #2 has MLPs seeing ALL ESI levels and seeing 50% of all pt's? That just sounds a bit unbelievable. Level 1 comes in and there is just as much chance that an MLP will be at the bed instead of a physician? If the docs are seeing on average 2.2 pph and signing an additional 0.8pph from a MLP, how are they seeing 50% of all patients? That doesn't add up. #2 doesn't sound bad to me if MLPs are seeing the majority of 4s and 5s leaving higher acuity pt's for the docs. That's how it works in my shop and I don't mind getting those charts. However, if it is as you described then that sounds like a dangerous environment and I would avoid.

Do you want to teach residents? If so, then #3 sounds fun. If not, then scratch it off your list.

Do you have loans? If so, 100K could go a long way towards paying them off and #2 looks more attractive.

Personally, I'd probably go with #1. Just keep your future plans to yourself. Plus, you never really know how you're going to feel 2 years from now. Those 2 years might turn into 5 or 10 very easily. 1.6pph with optimal staffing sounds like cake and is significantly less stressful than 2.5 or 2.6pph. 1 year partnership track with no buy in and included sign on? Sign me up. (Assuming all these offers are competitive for your area.)

 

[miacomet]

Are you sure #2 has MLPs seeing ALL ESI levels and seeing 50% of all pt's? That just sounds a bit unbelievable. Level 1 comes in and there is just as much chance that an MLP will be at the bed instead of a physician? If the docs are seeing on average 2.2 pph and signing an additional 0.8pph from a MLP, how are they seeing 50% of all patients? That doesn't add up. #2 doesn't sound bad to me if MLPs are seeing the majority of 4s and 5s leaving higher acuity pt's for the docs. That's how it works in my shop and I don't mind getting those charts. However, if it is as you described then that sounds like a dangerous environment and I would avoid.

Do you want to teach residents? If so, then #3 sounds fun. If not, then scratch it off your list.

Do you have loans? If so, 100K could go a long way towards paying them off and #2 looks more attractive.

Personally, I'd probably go with #1. Just keep your future plans to yourself. Plus, you never really know how you're going to feel 2 years from now. Those 2 years might turn into 5 or 10 very easily. 1.6pph with optimal staffing sounds like cake and is significantly less stressful than 2.5 or 2.6pph. 1 year partnership track with no buy in and included sign on? Sign me up.

Agreed, although I wouldn't count on the 100k for loans as either the job is such crap you won't put up with it or they will weasel out of the deal. People stay long than they think in a place- I would agree to think longevity, not a quick buck.

 

[Groove]

Agreed, although I wouldn't count on the 100k for loans as either the job is such crap you won't put up with it or they will weasel out of the deal. People stay long than they think in a place- I would agree to think longevity, not a quick buck.

Oh, I dunno. Where I work (region), there is a bigger demand for ABEM docs and these types of offers are not uncommon. If he's in a high supply region AND there are 100K sign on offers, then yes, I'd be wary... CMGs have a lot of liquidity and are able to toss around higher sign on bonuses like that. In my experience, the jobs are not always crap jobs though they are certainly not highly desired jobs either but many times are somewhere in-between.

If I signed on somewhere for 2 years with 100K sign on, I'd probably recommend negotiating a vesting clause where say... 50% of the bonus is vested after 1 year with month to month pro rata during the last year. I'm just thinking to how in debt I was after residency and I would have been willing to put up with ALOT for an immediate 100K to pay towards my loans. Now...not so much.

 

[cyanide12345678]

Are you sure #2 has MLPs seeing ALL ESI levels and seeing 50% of all pt's? That just sounds a bit unbelievable. Level 1 comes in and there is just as much chance that an MLP will be at the bed instead of a physician? If the docs are seeing on average 2.2 pph and signing an additional 0.8pph from a MLP, how are they seeing 50% of all patients? That doesn't add up. #2 doesn't sound bad to me if MLPs are seeing the majority of 4s and 5s leaving higher acuity pt's for the docs. That's how it works in my shop and I don't mind getting those charts. However, if it is as you described then that sounds like a dangerous environment and I would avoid.

Do you want to teach residents? If so, then #3 sounds fun. If not, then scratch it off your list.

Do you have loans? If so, 100K could go a long way towards paying them off and #2 looks more attractive.

Personally, I'd probably go with #1. Just keep your future plans to yourself. Plus, you never really know how you're going to feel 2 years from now. Those 2 years might turn into 5 or 10 very easily. 1.6pph with optimal staffing sounds like cake and is significantly less stressful than 2.5 or 2.6pph. 1 year partnership track with no buy in and included sign on? Sign me up. (Assuming all these offers are competitive for your area.)

The 40-50% is mostly my estimate. As a resident in the same hospital system, I can see the board of this particular hospital's ED. At most times, a majority of the patients have MLPs as primary, and attendings as supervisory role. 2.1-2.2 is the number given to me by the CMG, a lot of those are still primarily staffed by MLPs being supervised by the attendings (2s and 3s), but the attending will see the patient physically, and then there will be plenty that won't be seen by the attending (4s and 5s). The docs working there are fairly happy with the set up, they brag that their MLPs see most things. A family friend highly recommends the place, he has worked there for 20 plus years, and owned the group before selling to the CMG. But the MLPs there definitely see a surprising number of 2s and 3s in addition to 4s and 5s.

Number 2 is the most money. Number 1 is the least stress. The difference in money after taxes comes down to maybe 20k? Thats maybe a 7-8% increase in income for a 25% increase in patient load.

 

[cyanide12345678]

If I signed on somewhere for 2 years with 100K sign on, I'd probably recommend negotiating a vesting clause where say... 50% of the bonus is vested after 1 year with month to month pro rata during the last year. I'm just thinking to how in debt I was after residency and I would have been willing to put up with ALOT for an immediate 100K to pay towards my loans. Now...not so much.

The way the bonus is worded is the ****tiest way, I haven't negotiated it yet. Literally the bonus stipulation is that if I leave before the 2 years, then I will be responsible for paying back every penny that I've received as bonus. They actually are willing to give 150k for 3 years, I just don't want a 3 year commitment.

Also, truth be told, I'm not under much financial stress. I have about 190k in loans, but my spouse is also a resident with 0 in loans. We both live very simple lives, already have savings around 50k, I plan to start paying off my loan already with moonlighting money (made 12k moonlighting this month as a 3rd year).

 

[namethatsmell]

An important consideration are the required number of hours per month. Also, what is the % match for #3?

Job 1 sounds like the no brainer unless you want academics than pick #3.

I’ve worked at a place that became what job #2 sounds like...don’t do it.


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[Apollyon]

The $100k has to be ACS. HARD pass.

Take #1. Don't look back.

 

[RustedFox]

Number one.
No question about it.

 

[Groove]

The way the bonus is worded is the ****tiest way, I haven't negotiated it yet. Literally the bonus stipulation is that if I leave before the 2 years, then I will be responsible for paying back every penny that I've received as bonus. They actually are willing to give 150k for 3 years, I just don't want a 3 year commitment.

Also, truth be told, I'm not under much financial stress. I have about 190k in loans, but my spouse is also a resident with 0 in loans. We both live very simple lives, already have savings around 50k, I plan to start paying off my loan already with moonlighting money (made 12k moonlighting this month as a 3rd year).

I did a sign on during my first contract with current employer (CMG) and negotiated a clause much like the one I mentioned. You can't blame them for trying to stipulate a 100% pay back if you cut and run before the end of your 2 years as that is added incentive for you to stay, but most of these guys are very much open to reasonable negotiations. That being said, it sounds like you don't have enough reasons to go with #2 due to some instinctual hesitations and there is nothing wrong with that. #1 doesn't sound bad at all.

 

[Money Moniker]

The 40-50% is mostly my estimate. As a resident in the same hospital system, I can see the board of this particular hospital's ED. At most times, a majority of the patients have MLPs as primary, and attendings as supervisory role. 2.1-2.2 is the number given to me by the CMG, a lot of those are still primarily staffed by MLPs being supervised by the attendings (2s and 3s), but the attending will see the patient physically, and then there will be plenty that won't be seen by the attending (4s and 5s). The docs working there are fairly happy with the set up, they brag that their MLPs see most things. A family friend highly recommends the place, he has worked there for 20 plus years, and owned the group before selling to the CMG. But the MLPs there definitely see a surprising number of 2s and 3s in addition to 4s and 5s.

That midlevels are seeing the whole spectrum of acuity and doing a good enough job of it is terrifying for the long term viability of this specialty given how fast midlevel numbers are growing.

 

[miacomet]

Oh, I dunno. Where I work (region), there is a bigger demand for ABEM docs and these types of offers are not uncommon. If he's in a high supply region AND there are 100K sign on offers, then yes, I'd be wary... CMGs have a lot of liquidity and are able to toss around higher sign on bonuses like that. In my experience, the jobs are not always crap jobs though they are certainly not highly desired jobs either but many times are somewhere in-between.

If I signed on somewhere for 2 years with 100K sign on, I'd probably recommend negotiating a vesting clause where say... 50% of the bonus is vested after 1 year with month to month pro rata during the last year. I'm just thinking to how in debt I was after residency and I would have been willing to put up with ALOT for an immediate 100K to pay towards my loans. Now...not so much.

If he's in a high demand area, why such low hourlies?

 

[cyanide12345678]

That midlevels are seeing the whole spectrum of acuity and doing a good enough job of it is terrifying for the long term viability of this specialty given how fast midlevel numbers are growing.

I had a coversation with the family friend who was a partner in the group that held the contract prior to being bought out by the CMG, he basically explained that they had specifically trained these MLPs over many years. Their MLPs were trained in intubations and lines as well. They paid them extremely well compared to other places, and when the CMG took over the contract, the agreement was to retain these MLPs and pay them the same higher compensation compared to the market. These MLPs really do go in to see the 90 year old grandmas who are septic -_-

 

[cyanide12345678]

If he's in a high demand area, why such low hourlies?

I'm personally in a high supply area. If I move 60 miles east, I'll increase my salary 10%. Spouse is doing her residency though so we're stuck for a few years -_-

 

[cyanide12345678]

If he's in a high demand area, why such low hourlies?

And believe me....getting these "low hourly wages" itself was a struggle. The $215/hr job started negotiation at 190/hr. The 200/hr and 215/hr nights started at 185/hr with 80k sign on. Option 1 started at 185 without a sign on too. They all threw money at me when I told that I was moving ahead with another group, atleast I thought I was until they all offered a lot more than they originally did.

 

[Psai]

I had a coversation with the family friend who was a partner in the group that held the contract prior to being bought out by the CMG, he basically explained that they had specifically trained these MLPs over many years. Their MLPs were trained in intubations and lines as well. They paid them extremely well compared to other places, and when the CMG took over the contract, the agreement was to retain these MLPs and pay them the same higher compensation compared to the market. These MLPs really do go in to see the 90 year old grandmas who are septic -_-

smh. Good thing we go through medical school and residency so we can train these people while paying them well to do our jobs.

 

[RustedFox]

smh. Good thing we go through medical school and residency so we can train these people while paying them well to do our jobs.

- AND we're on the hook for when they eff up. Saying this with my unsworn statement for MLP medmal case scheduled late next month.

Either give them full practice rights and watch their numbers shrink as nobody hires them, or define what they can and cannot do.
The time has come, if you ask me.
I tire of people saying things like "I want to go to PA/NP school because (insert sentence about it being easier)."
Science is hard. Suck it up. Study.

 

[txterp98]

Personally, I'd go option 3.

Option 1 is painful for that commute. Upwards of a 50 minute commute? Ugh. You're waking up early, angry in traffic, tired after a shift, and then angry in traffic for another 50 minutes. If it weren't for that commute (and it's closer to the 35 minute estimate), then this would actually likely be my choice.

Options 2 & 3 are similar. Ultimately, you have increased liability for supervision. So, would you rather supervise MLP's or EM Residents? 25 minute commute is reasonable. And if Option 3 has a 401k match and Option 2 doesn't (like you stated), you have to get an idea how much this actually pushes up your hourly rate to make a more apples-to-apples comparison with Option 2.

Good luck with your decision. Once you make it, don't look back. Just like in the department, every decision we make is the best one for us at the time we made it.

 

[thegenius]

#1 to me is a no-brainer.

You are making, more-or-less, the same amount of money seeing 1.6/hr vs 2.2/hr.

That is a no brainer.

I work in two different hospital systems, and I see 2.23/hr at one place and ~1/hr at the other place. The second place is sooooo much nicer and I don't get burned out.

The other thing to consider is how easy it is to admit patients, or get consults to see patients. Hard to know that until you work at a place.

 

[GonnaBeADoc2222]

The OPs situation is different from most because his/her limited time frame to stay in the area.

I'm gonna throw my 2 cents in favor for option #2...here's why:

Choice #1 is the "forever job" obviously. Lower acuity, lower pph (honestly anything < 2 pph is a vacation). SDG. No brainer if you plan on staying long term - however even if staying long term must be concerned about CMG takeover as it seems there is significant CMG penetration into this area - but then again limited "buy in" mitigates this. The commute is manageable, but definitely on the longer end of things. I personally would not want to be driving 50 minutes in 7am rush hour traffic after a 12 hour overnight shift, falling asleep at the wheel.

Choice #2 is more money, more work...but it sounds like you have an army of well trained midlevels (I would KILL for motivated, well trained midlevels). Yeah yeah we can argue about the role of midlevels and what they mean for the future of the specialty, and I agree with those points, but who cares, you are there for 2 years. The commute of 5 minutes is so money - this point is huge. You could likely sign onto your spouse's health insurance for cheap.

People might disagree with me on this next point, but as this is your first job, and one that you plan on keeping for only 2 years, I think you should choose higher acuity and higher volume over lower acuity and lower volume. 2.2 pph isn't bad IF you have good scribes and solid nurses to alert you of stuff that you might have missed (important!). The reason I give for this (having just finished my first year as an attending myself) is that your first year out is such a steep learning curve (managing flow, managing your team, interpersonal challenges, etc) that you want to be at a place where you are dealing with sick patients and doing lots of your own procedures. I am happy to have been at a place like this where I am managing critical patients and intubating and placing lines regularly. Frankly, working in a semi-urgent care environment (which is what #1 sounds like) is a waste of your training this early - although definitely better to shift to this type of environment after a couple of years. The higher volume of midlevel chart signing IS a concern I would have.

Now, what I said goes out the window if:
1) 2.2 pph is really 3 pph
2) Scribes suck or are nonexistent
3) Nurses suck
4) Very poor consultant support

 

[Groove]

I live 5 mins from work and although there might be relatively equal compensation with a better work environment at 1 or even 2 alternate hospitals, my commute time is huge. I can roll out of bed and be at work within 10 mins. Once I leave my shift, I'm home in under 10 mins even with rush hour traffic. The convenience is a big factor for me, but then again... everyone is different. If you don't choose #2, that' fine but just make sure it's not because you are averse to signing MLP charts because that's just part of EM these days. Most jobs you take are going to involve a certain amount of MLP oversight. Personally, I've grown to enjoy our type of environment because I don't have to see all the vag complaints, lac repairs and corneal abrasions because most of the MLPs weed those out leaving me to see the higher acuity patients.

Then there's the 100K sign on... Anyway you try to minimize it...that's a lot of upfront cash at a time when you could probably use it. Just food for thought.

Any way to get credentialed at 2 of the ERs and PRN both for a couple of months and then decide?

 

[bravotwozero]

Yeah option 1 sounds the best except for your sucky commute time - any chance you can move to that location?


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[Tenk]

1.

 

[GeneralVeers]

Just remember, option 1 sounds great, but likely will be an easy target for a CMG, especially if profitable. There is always the risk that they buy the existing partners out before you make partner.

 

[cyanide12345678]

Just remember, option 1 sounds great, but likely will be an easy target for a CMG, especially if profitable. There is always the risk that they buy the existing partners out before you make partner.

That is frankly the biggest concern. This particular group had 4 hospitals 3 years ago, down to 2 now.

 

[cyanide12345678]

Good luck with your decision. Once you make it, don't look back. Just like in the department, every decision we make is the best one for us at the time we made it.

Wise words.

 

[cyanide12345678]

Yeah option 1 sounds the best except for your sucky commute time - any chance you can move to that location?


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I'd rather have a longer commute myself than my spouse have a long commute when she is in residency and working 6 days a week. Plus not to mention that she doesn't know how to drive in snow