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  • Deciding between two jobs

    I am a current senior dermatology resident looking to move back home to a moderate cost of living area. I have narrowed down the list to two jobs which I've received contracts, but am having a hard time deciding as both seem like great options. I will be practicing general dermatology some surgery and a small amount of cosmetics. I will not be doing Mohs. All of this before any negotiation.

     

    1) W2 job. 4day/5day alternating work week. Off day is Monday (prefer Friday but unavailable). $320k base. Bonus thresholds: 30% of collections after 700, 40% of collections after 850. Bonus paid annually. Partnership discussion after 2-3 years but currently only two partners (brother-in-laws) in early 50's so unsure of specifics. Working out of 3 offices. 45 minutes from parents. Do not collect any money from referred ancillary services such as aestheticians, skincare products, microneedling, light therapy, lasers, etc... That is billed under the practice owners. DEA, CME, health insurance for me, malpractice etc... are covered. 5 weeks PTO (vacation + CME). Huge non-compete based upon zip codes. Excellent reputation. Has strong affiliations with top notch dermatology residency for referrals, etc... Gave me references on 4 people who left, all of whom had nothing but positive things to say. After two year contract, most people switch to straight percent collections which is between 45-50%. Average EMR. Some of the ancillary benefits (CME, DEA, etc...) are dropped. 2 rooms/doctor.

     

    2) 1099 job. 4day/5day alternating work week. Off day is Friday. $25k/month guaranteed (equals 300k/year). Bonus thresholds is 46.5% after 50k in collections per month (which equates to bonus after 600k/year). As they work on a monthly basis, bonus paid monthly if above thresholds. No option for partnership. Currently the only gen derms are female so I may have larger male patient basis (visits are usually quicker with males). Working out of 2 offices, although only 1 day/week at the satellite office. About 25 minutes from my parents. I do get a referral fee for ancillary services: light is billed under my name, 30% of aesthetician services, etc... Malpractice is covered but I would be responsible for health insurance, CME, DEA, etc... 3 weeks PTO. Also has a pretty good reputation but not affiliated with major academic center. 2 providers have left although I was not able to contact them. They moved out of state. A former resident of my program has been working with them for ~10 months and enjoys it much better than her other practice. Smaller non-compete (10 miles). Allowed to wear scrubs to work. Superior EMR (although more costly to the practice). 3 rooms per doctor when I get high enough volume.

     

    -Factors favoring job #1: excellent reputation, partnership opportunity (although no formal options discussed), W2 for taxes (although can't put as much into retirement compared to solo 401k), referrals were excellent, CME/DEA/etc... covered, more PTO, higher base.

    -Factors favoring job #2: only have two work out of two offices (only one main one), bonus monthly, closer to parents (although not much of a difference), work with former resident who I have spoken with, better EMR, lower threshold to hit bonus, smaller non-compete, referral $ for ancillary services, higher contributions to retirement accounts (solo 401k), day off will be Friday.

    -No-difference: school districts (public schools are excellent in both), interactions with staff/faculty thus far (both have been great).

     

    I'm leaning toward job #2 but was curious regarding the opinions of the masses.

     

     

  • #2
    If job 1 is so great why did four people leave?

    Curious if the absence of formal partnership plan contributed.  Hard to imagine you would get what most here would consider fair shake with brothers in law as owners twenty years older than you   They will certainly retire and want a buy out which would need to be negotiated as well.   Inability to access ancillary income is concerning as it hints at asymmetric partnership opportunities.

    Obviously lot more factors than you can post here but food for thought.

    Comment


    • #3




      If job 1 is so great why did four people leave? Curious if the absence of formal partnership plan contributed. Hard to imagine you would get what most here would consider fair shake with brothers in law as owners twenty years older than you They will certainly retire and want a buy out which would need to be negotiated as well. Inability to access ancillary income is concerning as it hints at asymmetric partnership opportunities.
      Click to expand...


      This.

      Having worked for 7 years for a large group that had only the male doc and his wife, also a doc as the only partners you have zero chance of getting a partnership. They will squeeze you and throw you out. Trust me on this, I have gone through this in my past medical life. And the large non compete area means you are screwed should you dislike it by year 2 or so not get the expected partnership.

      For job 2, I hope you realize as 1099 you have to pay 6.2% + 1.45 % additional employer component on SS and Medicare for the 1st 127K or so ( it changes each year). And health benefit costs, licenses, DEA , CME. All add up to a pretty sum. Subtract that from your compensation.

      Why not open your own practice in the location where the 2nd job is situated. If the volume is as high as is claimed, you will have a busy practice in no time.

      Comment


      • #4
        Thanks to those who have replied already. As to the couple of additional points brought up:

        -Practice 1: the people who I spoke with and left, all did for family reasons. A few of them were new grads who took a job for a few years waiting for their spouses to finish up longer training. Once there spouse was finished, then they moved.

        -I do get "concerned" about brothers-in-law and partnership options as it's never been done before. It would be more of a risk for sure.

        -1099: I did my best to calculate the additional tax burden to the best of my knowledge. For instance, the additional tax up to the SS limit of 128700 (6.2+1.45) will be $9,846. From 128,700 to 250k the additional burden would be $1,759 (1.45% Medicare). For income above 250k, it would be 2.35% (1.45+0.9 of additional obamacare tax). Therefore, as hypotheticals if I make $350k, my ADDITIONAL tax liability would be ~$14000. At the top end of the payscale (more for reference as I don't think I'd get there), at $800k, my additional tax would be ~$25000. That is only taxes as DEA, CME and health insurance (trying to price it out now for healthy family of 4) are not reflected in that.

        -As to opening up my own shop, I did think about doing that but probably not the best option for me at the present moment right out of training. It could be something I consider in the future. However, for the FIRE folks amongst us, there is a lot of opportunity cost to setting up your own shop and making good money now could allow me to retire in ~10-12 years.

         

        Comment


        • #5
          At the end of the day, do you want to be an employee forever, or a partner with decision-making capacity and potential higher ceiling of reimbursement? That's a fundamental question you have to ask yourself.

          If you do want to become a partner, getting those logistics nailed down as much as possible before you sign is always better. Even then, it is more risky. But, there is something very liberating about being somewhat of your own boss (you are truly never your own boss).

          Comment


          • #6




            Thanks to those who have replied already. As to the couple of additional points brought up:

            -Practice 1: the people who I spoke with and left, all did for family reasons. A few of them were new grads who took a job for a few years waiting for their spouses to finish up longer training. Once there spouse was finished, then they moved.

            -I do get “concerned” about brothers-in-law and partnership options as it’s never been done before. It would be more of a risk for sure.

            -1099: I did my best to calculate the additional tax burden to the best of my knowledge. For instance, the additional tax up to the SS limit of 128700 (6.2+1.45) will be $9,846. From 128,700 to 250k the additional burden would be $1,759 (1.45% Medicare). For income above 250k, it would be 2.35% (1.45+0.9 of additional obamacare tax). Therefore, as hypotheticals if I make $350k, my ADDITIONAL tax liability would be ~$14000. At the top end of the payscale (more for reference as I don’t think I’d get there), at $800k, my additional tax would be ~$25000. That is only taxes as DEA, CME and health insurance (trying to price it out now for healthy family of 4) are not reflected in that.

            -As to opening up my own shop, I did think about doing that but probably not the best option for me at the present moment right out of training. It could be something I consider in the future. However, for the FIRE folks amongst us, there is a lot of opportunity cost to setting up your own shop and making good money now could allow me to retire in ~10-12 years.

             
            Click to expand...


            here's a free clue for a newbie. 

            family reasons are always cited.  means nothing.  no one wants to be known as someone who bad mouths anyone.  especially if someday you are going to need a reference.

            i don't think you can rely on someone's opinion who knows going in that it is a temporary situation.  they don't care about longterm options.  they don't even care about best package in the short term.  they may only care about having a job while spouse finishes.  they may only care about maxing short term pay.

            if they've gone through four people and don't have a formal partnership track plan, odds are approaching 100.00% for you getting shafted (at least by the values of the group of posters here).  doesn't mean the partners are not nice people.  doesn't mean they are not outstanding clinicians.  doesn't mean they can't put on a nice dog and pony show.  but when it comes to true partnership, decision making, and money, you will always be outvoted 2:1.  when it comes time to buy them out, you will get shafted.  when you figure out all the ways they have been shafting you, you will be mad.  do they own the building?  are you going to get a share of that?  are they going to keep owning the building after selling you the practice?  how is rent determined?  what about all those ancillaries?  why such a big noncompete?  is it enforceable in your area?

            respectfully, it is only a few people who are new graduates who can consider all the nuances of running a business.  and truthfully, i have enough clinical medicine to teach most new graduates that i would worry if they were too focused on the business end.  it is hard to teach new hires thoughtfully and without hurting any feelings.  it takes a big time commitment.  i don't know anything about derm, but i would generally encourage most new graduates to continue to develop clinical skills first.  especially if you are going to an employed situation.  you can learn the business side more slowly.

             

            Comment


            • #7
              I'd be concerned about the lack of specifics with the partnership track in option 1. Any chance of having this nailed down in a contract to state that partnership will be met assuming certain productivity thresholds and no practice damaging issues? I'm dealing with the same thing right now where I see little to no incentive for a partner, specifically when there is only 1 other physician who is a partner, to make you a partner. Curious to hear other people's opinions on this aspect of becoming a partner and how to best safeguard against getting screwed.

              Comment


              • #8


                As to opening up my own shop, I did think about doing that but probably not the best option for me at the present moment right out of training. It could be something I consider in the future. However, for the FIRE folks amongst us, there is a lot of opportunity cost to setting up your own shop and making good money now could allow me to retire in ~10-12 years.
                Click to expand...


                How far apart are the main office and satellite office of the 2nd job. Does the 10 mile non compete apply to each and do they overlap. You might find that much bigger than you assumed ( and difficult to fight even if they are not enforceable). So you might not be able to open any practice in that area even with a small on compete radius, after working 2-3 years.

                Dermatology office is easy to set up compared to cardiology. There are many cash pay patients. If you are your own boss you can use depreciation on items purchased. And take part of income as salary and part as distributions to not have to pay Medicare tax on that portion. If your spouse works and can bring in a living wage you won't be under great pressure to bring in income from day 1.

                Comment


                • #9
                  I'd be wary of the "potential" partnership at job one, especially if 4 people recently left.  Even if for family reasons, high turnover is a big red flag for a job. Maybe they realized they werent going to make partner, and had to leave far away due to the non compete? Whatever you choose I would advise not buying a house in the first few years until you really know the practice- some malignant practices may bank on dangling a carrot (partnership, bonuses) in front of new grads, only to pull it away once it becomes harder for the new employee to leave (bought a house, need to move for non compete, complacency).  You will always have the most leverage before you start the job, so ask for everything to be put in writing in the contract.  I myself was fooled in the past with a partnership offer for 3 years, only to realize the senior partners have all the deciding votes so the junior partners basically had no decision making ability. For that job it took me 2 years in to realize, and I saw how the practice used this to their advantage as they basically dared the people who bought houses already to look for other jobs far away (strict non compete involved also) and never gave them raises, declined to match any offers, etc.

                  Comment


                  • #10
                    Neither looks perfect, but option 2 is definitely better. Really the only negatives are no partnership and no healthcare, but in my opinion you will not be offered a fair partnership with option 1 if you are even offered one at all. Also, don’t underestimate the quality of the EMR in derm. It makes a huge difference. Finally, working out of 2 rooms will make it difficult to hit your bonus thresholds.

                    You should make more money in option 2 based on the structures you laid out. I would still try to negotiate a higher salary to offset lack of health insurance and CME. Also maybe negotiate 1 more week PTO. Lack of partnership is not as big a deal since you get a percentage of your ancillary referrals. Also, you always have the option to go out on your own since the non-compete is not too onerous.

                     

                    Comment


                    • #11
                      not in a field w/ private practices like this, but 2 family members running an office with 4 non family docs having come and gone would be about the biggest red flag i could think of.

                      it would take very special people to treat a third doc who wasn't at their thanksgiving meal and who was a new grad completely fairly. i'd be worried about a lot of smiles and shrugs about things like weekend/holiday call etc.

                      Comment


                      • #12







                        Thanks to those who have replied already. As to the couple of additional points brought up:

                        -Practice 1: the people who I spoke with and left, all did for family reasons. A few of them were new grads who took a job for a few years waiting for their spouses to finish up longer training. Once there spouse was finished, then they moved.

                        -I do get “concerned” about brothers-in-law and partnership options as it’s never been done before. It would be more of a risk for sure.

                        -1099: I did my best to calculate the additional tax burden to the best of my knowledge. For instance, the additional tax up to the SS limit of 128700 (6.2+1.45) will be $9,846. From 128,700 to 250k the additional burden would be $1,759 (1.45% Medicare). For income above 250k, it would be 2.35% (1.45+0.9 of additional obamacare tax). Therefore, as hypotheticals if I make $350k, my ADDITIONAL tax liability would be ~$14000. At the top end of the payscale (more for reference as I don’t think I’d get there), at $800k, my additional tax would be ~$25000. That is only taxes as DEA, CME and health insurance (trying to price it out now for healthy family of 4) are not reflected in that.

                        -As to opening up my own shop, I did think about doing that but probably not the best option for me at the present moment right out of training. It could be something I consider in the future. However, for the FIRE folks amongst us, there is a lot of opportunity cost to setting up your own shop and making good money now could allow me to retire in ~10-12 years.

                         
                        Click to expand…


                        here’s a free clue for a newbie.  ????

                        family reasons are always cited.  means nothing.  no one wants to be known as someone who bad mouths anyone.  especially if someday you are going to need a reference.

                        i don’t think you can rely on someone’s opinion who knows going in that it is a temporary situation.  they don’t care about longterm options.  they don’t even care about best package in the short term.  they may only care about having a job while spouse finishes.  they may only care about maxing short term pay.

                        if they’ve gone through four people and don’t have a formal partnership track plan, odds are approaching 100.00% for you getting shafted (at least by the values of the group of posters here).  doesn’t mean the partners are not nice people.  doesn’t mean they are not outstanding clinicians.  doesn’t mean they can’t put on a nice dog and pony show.  but when it comes to true partnership, decision making, and money, you will always be outvoted 2:1.  when it comes time to buy them out, you will get shafted.  when you figure out all the ways they have been shafting you, you will be mad.  do they own the building?  are you going to get a share of that?  are they going to keep owning the building after selling you the practice?  how is rent determined?  what about all those ancillaries?  why such a big noncompete?  is it enforceable in your area?

                        respectfully, it is only a few people who are new graduates who can consider all the nuances of running a business.  and truthfully, i have enough clinical medicine to teach most new graduates that i would worry if they were too focused on the business end.  it is hard to teach new hires thoughtfully and without hurting any feelings.  it takes a big time commitment.  i don’t know anything about derm, but i would generally encourage most new graduates to continue to develop clinical skills first.  especially if you are going to an employed situation.  you can learn the business side more slowly.

                         
                        Click to expand...


                        OP is also in a tiny field in what sounds like a fairly small metro (from description of COL, schools etc). Like q is saying you're really unlikely to get an honest take on the practice from docs who have exited in a situation like that. They have nothing to gain by warning you about bad stuff and a decent amount to lose.

                        Comment


                        • #13
                          Sorry, neither job sounds particularly enticing to me. #2 sounds better than #1. To me, the only thing attractive about #1 is that it’s in your preferred location.

                          Comment


                          • #14
                            If your interest is general dermatology, then there are very few areas in the country where you couldn't just start up your own practice and be as busy as you want to be in 2 years.  You will ultimately make more money (but years one and two will be much less) and have more flexibility.  That's what you should do.

                            I'd agree that 2 is better than 1 if you're forced to pick between those two.

                            Comment


                            • #15
                              There are probably options other than these if you want to take more risk. I was never into working for anyone else so I have worked for myself from the get go. In terms of the actual set-up of a dermatology room, I guess that would be more than an office but not a large capital expense. The first 3 years are a steep learning curve for any area of medicine. I joined a multiple peer review groups and learnt a lot from that.

                              Here are 2 ideas that are out of the square:

                              1. Your ideal match is a dermatologist who is in middle age and not interested in selling their practice or taking on associates (until you prompt them to). I have no idea about whether such people exist in dermatology in areas you are looking for. Such people do exist in my area of medicine. They are not likely to be working in a teaching hospital or even attending many conferences. Maybe you could look at areas where there is demand for dermatologists (low density per population) and an upward income trajectory, where you would want to live. Ring the few dermatologists who are in the area and find out if they are willing for you to work with them/rent a room from them with a view to buying their practice. I was never interested in buying anyone's practice so I just asked to rent a room.

                              2. If you can't find a dermatologist to rent a room from then some other minor proceduralist: here you could team up with say an ENT surgeon who wants to start. There would be no competition between you and perhaps a mild synergy in terms of referrals. Perhaps you could call it :  the ear, nose and skin clinic. Or the wholistic face clinic.

                              3. You could also work out of a G.P practice but other G.P practices would be reluctant to refer to you, seeing you as working for the competition.

                              4. I once worked out of a spare office in my wife's dental surgery for a few months. I thought about renting a room from a Neurosurgeon but my wife was easier. Plenty of rooms out there that are vacant for a day or 2 a week. Check that there is approval from the local council or whoever regulates that in your area.

                              5. You could set up an office in the back of your house subject to approval. But I haven't ever done this because of security concerns.

                              What I have avoided is:

                              - signing any non-compete agreements that restricted my future practice location

                              - I made sure I kept control of my medical records and could take them when I left (except at hospitals where the hospital medical records kept this)

                              - If you can have a separate phone number, even a mobile number for appointments, this makes moving easier.

                              - I tried to avoid renting or sharing rooms with anyone with serious problems like an alcoholic clinician. Other than that though, I didn't mind if they were eccentric, because I am not quite average myself.

                              - I avoided working with anyone who was a Professor because I found they were quite difficult (but then that is just my limited experience in terms of work relationships and that may not be the case for anyone else).

                               

                               

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