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First Job Graduating Fellow Questions

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  • First Job Graduating Fellow Questions

    Gastroenterology fellow here looking for advice about first job out of fellowship:

    Currently single and free to move anywhere in the country.

    If anyone could or would be willing to provide any insight into the following questions I would greatly appreciate:


    1. In looking at job opportunities, it seems like the primary distinction is between employed by a hospital vs private practice. Gastroenterology from what I understand is one of the main utilizers of ambulatory surgery centers ASC (with also ortho, pain, urology).

    With this in mind, I feel like I would be missing out on a major opportunity if I took an employed job that did not have the potential for ownership/stake in an ASC. I am very interested and willing to learn the business aspects of medicine. I am single and young and do not mind working long hard hours early on in my career if this means more potential income and control in the long run rather than working for someone else.

    Is it reasonable to only want jobs that provide potential ownership in an ASC? Is this a major flow of income for those physicians who own an ASC? Is this even a smart move/reasonable line of thinking?


    1. How much does payer mix matter? I see this mentioned in job offers but I am uneducated as to why or how much this matters? Going to assume that more private insurance rather than Medicare/Medicaid will reimburse at higher rates? Should this be a major concern of mine? What is a good mix or percentage of private to Medicare I should be looking for?


    1. What exactly in an RVU? I assume it is extra money you generate per number of procedures that you are compensated on top of your normal salary. Is there a standard RVU rate? Or is this negotiable? What even is a “good RVU rate”?


    1. Is there anything not mentioned above that you wish you had known or been told about before entering your first job out of training? I read that the majority of physicians change jobs within the first 3-6 years out of fellowship because they are dissatisfied with something. What exactly are they unhappy with? What pitfalls should I be looking out for?


    I feel like fellowship does not train or give you any information about the practicalities of entering the physician workplace. I am willing to work hard, feel like I picked an in-demand specialty (judging by the 50 recruiter emails daily in my inbox). Given the abundant job offers I feel like gastroenterology is in much demand and wish to make smart decisions. Definitely feel my training has been lacking in this area of more practical medical business education. And when I try to ask these questions in an academic setting you would think I was talking about murdering innocent children it’s so taboo…

    Any advice and insight are greatly appreciated. Thank you!




  • #2

    Gastroenterology fellow here looking for advice about first job out of fellowship:
    Click to expand...

    We are looking for a gastroenterologist... but would be employed, no ASC. PM me if you want to know details, amazing work/life balance with awesome area to live and amazing medical staff, like family.

    What exactly in an RVU? I assume it is extra money you generate per number of procedures that you are compensated on top of your normal salary. Is there a standard RVU rate? Or is this negotiable? What even is a “good RVU rate”?
    Click to expand...

    wRVU stands for "work Relative Value Unit" and Medicare assigns a number to each office visit, procedure, etc. This is how lots of employed arrangements work, that you get paid a certain dollar amount (negotiable) per wRVUs. The nice part (at least where I am) is that the payor mix does not matter, as you get paid a certain amount for the work you do, whether the hospital gets paid by commercial insurance or the eat the cost with a self-pay that will never pay. There is data from MGMA and others on salary surveys that can give you the median $$/wRVU that a gastroenterologist gets paid.


    • #3
      Not to intentionally brush you off, but it may be a better use of your time than refresh....

      Search the forum with keywords from your questions since a good chunk of what you asked has been discussed at some point in the recent past (last 2 years). Also, the WCI podcast has some episodes about ASCs.

      I'm an employed radiologist. Payer mix matters when private, not as much as employed. Benefits of employment by a large hospital corporation is that the target isn't necessarily you when it comes to malpractice. Drawback is that what they say typically goes when it comes to money.

      And always remember, negotiate.

      Good luck.


      • #4
        I agree that plenty programs do not discuss non-academic jobs or the business of medicine much, some seem to really look down on it, despite the fact that most go into clinical/PP careers.

        1. PP vs employed.  Do a search and read up on this, lots of info and posts on WCI about this.  If you're open to learning the business, running it, then it can be a fine option, but it's not without downsides.  I've read and heard of plenty PP horror stories; empty promises, failed partnerships, etc.  The idea of starting out PP, either solo or joining a group, certainly carries some risks.  And as you said, lots of folks leave their first jobs with a few years.

        2. Payer mix matters if you're paid by collections/billing.  If you're patients are all medicare/medicaid you're simply not going to be collecting much money.  wRVU, you're paid by work unit, payer is typically irrelevant.  Pros/cons to both.

        4. Various reasons people leave. Personal reasons, priorities change, figure out what they want in life/career, job isn't a good fit, figure out how they like to practice, etc.

        I know one recent GI grad who got a pretty good job in good area, so there's potential out there.  Just gotta figure out what you want, what's important to you, how you want to practice, who you want to work with, etc.  Going after $$$ likely isn't the best approach.


        • #5
          PP vs Employed - best is small group private practice. In very simplistic terms, you are your own boss, but the size of group allows you to have manager to take care of running the practice so you can spend more time with family. You would spend 1/2 time away from office doing procedures so solo practice is not economical enough way, and compliance is going to drive you nuts.

          When evaluating job offers you will come across many differently structured offers because there is so many moving parts. Best is to focus on total annual income potential because sometimes employment is much better then ownership. Let me illustrate with examples:

          * Example 1: Job A - ASC and anesthesia ownership in 3 years with buy in, partner in office in 2 years, starting salary $400,000 vs Job B: employed position paying  $600,000. Assume similar call/office work load.

          --  More details for Job A: ASC is 51% owned by AmSurg, annual distribution for ASC plus anesthesia is $150K/yr and buy in $450k. Office collections after 50% overhead is $400,000 annually. So in year  3 you would make $550k ($150k + $400K, after paying $450k). Job B is much better, isn't it?

          * Example 2: Job A: Starting salary $400,000, path and anesthesia ownership, no ASC ownership. Partner in office in 2 years, partner in anesth/path in 3 years. Job B: employed $600,000

          -- More details for job A: Once partner in office actual collections after 50% overhead are $600,000. Path and anesthesia - $400,000 annual income. So total compensation once all in is $1 mil/yr. Better then job B?

          Our group is hiring a Gastroenterologist. One of the best offers you can get out there in private practice, in a desirable location. PM me if want to find out details.