Help!!!

[happy optho]

Hello all

I have been reading some of the posts here and I was shocked at the anguish of some ppl who are upset with their salaries,

I need someone to tell me :

Is this a the overall trend or are these some selected cases,

I am actually going to practice where ever the best offer is and not necceassirly the most desirable area ( the rukes of supply and demand)

are there ophthgst here who started off getting low wages but then as the years progressed theit income improved.

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[Eyefixer]

No offense dude, but you've managed to misspell "Ophtho" in your forum user name. That's just too funny.

 

[happy optho]

I know that other name was taken

 

[orbitsurgMD]

Hello all

I have been reading some of the posts here and I was shocked at the anguish of some ppl who are upset with their salaries,

I need someone to tell me :

Is this a the overall trend or are these some selected cases,

I am actually going to practice where ever the best offer is and not necceassirly the most desirable area ( the rukes of supply and demand)

are there ophthgst here who started off getting low wages but then as the years progressed theit income improved.

REQUEST DENIED.

Seriously, ophthalmology incomes have descended from the lofty levels of the 1980s and early 1990s and continue to decline on the per-unit-worked basis, offset only by increased productivity. You will not earn a high six figure income seeing twenty patients a day and doing the surgery that comes from that patient volume. There was a time when you could do just that. The rules have been rewritten by Medicare and major carriers, and there isn't much anyone has been able to do about it. If the current administration implements a broadly-available version of Medicare for the population presently without coverage, you can expect a lot more of the same. All that stimulatin' is going to have to be repaid and bloated Medicare budgets aren't going to work with that plan.


In the past, when there weren't annual programmed cuts that eroded the effects of natural new practice growth, it was reasonable to say that one could expect a steady growth in personal income once a practice was started and matured. These days, the truth is that nobody really knows. Medicare is a good example of how unpredictable revenue can be: up to double digit annual programmed payment reductions under the guise of "sustainable growth" limitations, which is to say they really do know they cannot continue to pay for the quantity of care they have committed themselves to provide U.S. beneficiaries who paid taxes all their working lives with the expectation that, one day, the same benefits would be given to them.

No one can give you reassurance that you will see a regular and progressive growth in personal income. In fact, if you look at the evidence from those who practiced during the past twenty years, you will have confirmation that you now have to work much harder to earn the same or less income.

Declining incomes do many things. They delay retirements of older doctors who might have sold their developed practices to new graduates that could expect to repay the buyout costs in a predictible time period without crippling their personal lives with oversize debt repayment. No more.

Less money makes starting offers poorer, offers to graduates who have historically greater amounts of accrued educational debts than any people in history. Not good.

Less money delays buying or upgrading pracice equipment an recoupment of costs becomes questionable, even under conditions of higher throughput--volume--which you can't always count on. And as payments under Medicare are cut for many procedures, the costs of capital equipment have increased, making the recoupement of capital investment a longer and less-certain process.

 

[Eyefixer]

Totally 100% agree with above. It's not looking good for medicine in general, but Ophthalmology specifically. Specialties like GI, Cards, Surgery, etc. at least have hospital backing because hospitals can not function without these services. Unfortunately, Ophthalmology is not a necessary service, especially for smaller hospitals. When I was interviewing for positions, I looked to smaller hospitals in rural areas for financial backing; most were not interested. At the same places, my graduating GI and Cards colleagues we getting $500K starting offers. They don't tell you that in residency .

REQUEST DENIED.

Seriously, ophthalmology incomes have descended from the lofty levels of the 1980s and early 1990s and continue to decline on the per-unit-worked basis, offset only by increased productivity. You will not earn a high six figure income seeing twenty patients a day and doing the surgery that comes from that patient volume. There was a time when you could do just that. The rules have been rewritten by Medicare and major carriers, and there isn't much anyone has been able to do about it. If the current administration implements a broadly-available version of Medicare for the population presently without coverage, you can expect a lot more of the same. All that stimulatin' is going to have to be repaid and bloated Medicare budgets aren't going to work with that plan.


In the past, when there weren't annual programmed cuts that eroded the effects of natural new practice growth, it was reasonable to say that one could expect a steady growth in personal income once a practice was started and matured. These days, the truth is that nobody really knows. Medicare is a good example of how unpredictable revenue can be: up to double digit annual programmed payment reductions under the guise of "sustainable growth" limitations, which is to say they really do know they cannot continue to pay for the quantity of care they have committed themselves to provide U.S. beneficiaries who paid taxes all their working lives with the expectation that, one day, the same benefits would be given to them.

No one can give you reassurance that you will see a regular and progressive growth in personal income. In fact, if you look at the evidence from those who practiced during the past twenty years, you will have confirmation that you now have to work much harder to earn the same or less income.

Declining incomes do many things. They delay retirements of older doctors who might have sold their developed practices to new graduates that could expect to repay the buyout costs in a predictible time period without crippling their personal lives with oversize debt repayment. No more.

Less money makes starting offers poorer, offers to graduates who have historically greater amounts of accrued educational debts than any people in history. Not good.

Less money delays buying or upgrading pracice equipment an recoupment of costs becomes questionable, even under conditions of higher throughput--volume--which you can't always count on. And as payments under Medicare are cut for many procedures, the costs of capital equipment have increased, making the recoupement of capital investment a longer and less-certain process.

 

[happy optho]

I understand how these experiences will make anyone bitter but I still see job postings - even for general ophthalmologists- with starting income of 200+ k.

Also the cards and GI ppl who are getting these salaries work extra extra to maintain this salary, I doubt that they will only see 20 pts a day and do 2 caths a week or two colonoscopies a week and make this income.

plus go into any hospital at 2 AM; I assure you that your are way more likely to see a crds or GI specialist in the ED seeing an emergent case rather than an ophthalmologist--> it does not matter how much you make if you are not goint to have time to spend it !!

I honestly do not think it can be all that bad, you make it sound that we will be making less than nurses for God sake!!!

 

[orbitsurgMD]

I understand how these experiences will make anyone bitter but I still see job postings - even for general ophthalmologists- with starting income of 200+ k.

Certainly not as many as there used to be, and those that are offering high salaries to start usually have some substantial reason for doing so. Undesirable locations, practices that have histories of revolving door hiring or some other reason they feel it necessary to offer significantly more than average salaries.

Also the cards and GI ppl who are getting these salaries work extra extra to maintain this salary, I doubt that they will only see 20 pts a day and do 2 caths a week or two colonoscopies a week and make this income.

Same for ophthalmologists. If you want to earn like the cards and GI specialists mentioned, you will need to see 40-50 patients a day.

plus go into any hospital at 2 AM; I assure you that your are way more likely to see a crds or GI specialist in the ED seeing an emergent case rather than an ophthalmologist--> it does not matter how much you make if you are not goint to have time to spend it !!

Doubtful. GI and Cards specialists don't like middle-of-the night work any more than anyone else. That is why many are starting specialist hospitals and endoscopy clinics independent of hospitals, just to avoid the middle-of -the-night requests that, not only are inconvenient but often go unpaid.

I honestly do not think it can be all that bad, you make it sound that we will be making less than nurses for God sake!!!

I am all ears if you have evidence to the contrary. But as a medical student, I am curious to know why you should doubt the accounts professionals who are actually doing the work and know the present conditions of practice costs and third-party payment. And as for making less than nurses, that is nothing new. CRNAs make more than starting ophthalmologists in many places. So do dentists.

 

[CuriousKat]

I just caught up with a roommate from med school who is finishing up a vitrea-retina fellowship and the guy accepted a job in the San Diego area...for 150K starting and a 3 year partnership track. He just signed a lease to live in a studio apartment. As an attending. WTF?

It is a little better in gas but it is not the holy grail by any means.

 

[7ontheline]

The decrease in $$$ is hardly specific to ophthalmology. You'll find similar stories in many specialties. Ophtho is notable because it had such a big reputation for huge salaries and low work loads, which obviously doesn't work these days. Still, every physician is having to do more and see more patients to make the same money as previously.

 

[Just Applied]

The question to the person stating a collegue offered a starting salary of 150,000. Was that academic or private?

-JA

 

[DOCTORSAIB]

I just caught up with a roommate from med school who is finishing up a vitrea-retina fellowship and the guy accepted a job in the San Diego area...for 150K starting and a 3 year partnership track. He just signed a lease to live in a studio apartment. As an attending. WTF?

It is a little better in gas but it is not the holy grail by any means.

I never understood why people start out their careers in places like SD, LA, NYC, etc. It's the WORST decision from a financial point of view. And there is less room for growth.

The other thing I don't get is why so many grads wimp out and join someone elses practice. I may be a little wet behind the ears at this stage of the game but the risk of me borrowing 500K to start my own gig is INFINITELY better than me severely undervaluing myself, starting out at 150K as a retina surgeon working for someone else.

The guys who hire others started their own practice at some point. Why can't I?

Thoughts?

 

[happy optho]

Doubtful. GI and Cards specialists don't like middle-of-the night work any more than anyone else. That is why many are starting specialist hospitals and endoscopy clinics independent of hospitals, just to avoid the middle-of -the-night requests that, not only are inconvenient but often go unpaid.

once again you bring up the same argument, I do not think that you can consider NJ a remote area, or Florida , but that is beside the point, I have a friend who is a GI fellow who signed up for one of those 500K jobs, he likes the money but the group that hired him told RIGHT OFF THE BAT to expect to be called in to the hospital that they would cover almost half to 75 % of the time he is on call.

bottom line is this ........

work your ***** off you will make money, Gas or Rads may do less physical work, but they spends the same time ( 12 hour days ) non the less if they want to make the big bucks......

I will go back to my original point :

do what you like and spend more time spending what you have rather than spending more time trying to place yourself in a higher tax bracket and losing almost half of what you will make in taxes.

also when someone speaks of those predatory senior ophthalmologist, if they are able to let go of 150 K a year; they have to be making more than that or else they would keep it to themselves, AKA at some point we will get to that point as ophthalmologists, we just need to be patient.

but I do understand the frustration of not being able to be well compensated right off the bat as other specialties do, but on the other hand we do not start off with as many cases as they do, I think you yourself mentioned that it takes a whole year for a starting ophthalmologist to build the pt base to cover the costs of him starting out.

 

[orbitsurgMD]

I never understood why people start out their careers in places like SD, LA, NYC, etc. It's the WORST decision from a financial point of view. And there is less room for growth.

The other thing I don't get is why so many grads wimp out and join someone elses practice. I may be a little wet behind the ears at this stage of the game but the risk of me borrowing 500K to start my own gig is INFINITELY better than me severely undervaluing myself, starting out at 150K as a retina surgeon working for someone else.

The guys who hire others started their own practice at some point. Why can't I?

Thoughts?

Times have changed. You can start a practice, but you will need financing (unless you are wealthy, and don't need to borrow for startup costs). Coming to the table with large net negative equity leaves you at a disadvantage if you can even get a loan. Most banks want to see you put something up to secure their money. Many new grads don't have any assets to do this.

In the good old days, before my time, the break-even point was low. Educational debts were low, living costs were much lower than today, office operating costs were lower and third-party payment was huge. You could be in the black on one or two cataract surgeries a week. After that, there was no looking back.

It was a sure thing to buy or launch a practice back then. Not so now. The break-even point is much higher and banks and other lenders are well aware of how the calculus has changed.


Overserved markets have always paid worse. The break-even point was always higher there.


Borrowing $500K isn't as easy as you think unless you or someone is able to put up a large equity stake as collateral, as in their house or a decent size deposit account or a stock portfolio. Having an M.D. and a desirable residency behind you, even with great credit, does not make for automatic easy lending.

 

[orbitsurgMD]

Doubtful. GI and Cards specialists don't like middle-of-the night work any more than anyone else. That is why many are starting specialist hospitals and endoscopy clinics independent of hospitals, just to avoid the middle-of -the-night requests that, not only are inconvenient but often go unpaid.

once again you bring up the same argument, I do not think that you can consider NJ a remote area,

Depends. Pine barrens. Vineland. The northwest corner. It isn't all metro NYC and Philadelphia.

......

I will go back to my original point :

. . . if they are able to let go of 150 K a year; they have to be making more than that or else they would keep it to themselves, AKA at some point we will get to that point as ophthalmologists, we just need to be patient.

but I do understand the frustration of not being able to be well compensated right off the bat as other specialties do, but on the other hand we do not start off with as many cases as they do, I think you yourself mentioned that it takes a whole year for a starting ophthalmologist to build the pt base to cover the costs of him starting out.

A practice able to hire should already have a patient base to justify the hire.
It will usually take less than a year to cover the net added cost of the new hire. In other words, they should be clear all additional costs by the new doctor's production within the year. That doesn't mean the doctor is meeting the expected production levels; many practices want to profit on new hires.

 

[DOCTORSAIB]

Times have changed. You can start a practice, but you will need financing (unless you are wealthy, and don't need to borrow for startup costs). Coming to the table with large net negative equity leaves you at a disadvantage if you can even get a loan. Most banks want to see you put something up to secure their money. Many new grads don't have any assets to do this.

In the good old days, before my time, the break-even point was low. Educational debts were low, living costs were much lower than today, office operating costs were lower and third-party payment was huge. You could be in the black on one or two cataract surgeries a week. After that, there was no looking back.

It was a sure thing to buy or launch a practice back then. Not so now. The break-even point is much higher and banks and other lenders are well aware of how the calculus has changed.


Overserved markets have always paid worse. The break-even point was always higher there.


Borrowing $500K isn't as easy as you think unless you or someone is able to put up a large equity stake as collateral, as in their house or a decent size deposit account or a stock portfolio. Having an M.D. and a desirable residency behind you, even with great credit, does not make for automatic easy lending.

Doc,

Your advice is always appreciated in this forum. Thanks.

I have the next 5 years (residency + fellowship) to set the stage. I'll make it happen.

 

[7ontheline]

I never understood why people start out their careers in places like SD, LA, NYC, etc. It's the WORST decision from a financial point of view. And there is less room for growth.

The other thing I don't get is why so many grads wimp out and join someone elses practice. I may be a little wet behind the ears at this stage of the game but the risk of me borrowing 500K to start my own gig is INFINITELY better than me severely undervaluing myself, starting out at 150K as a retina surgeon working for someone else.

The guys who hire others started their own practice at some point. Why can't I?

Thoughts?

I agree with orbitsurg. You are being a little naive with regards to the economic environment out there today. It is true that if you are willing to work hard and grind it out then you have a good chance of succeeding, but there is no guarantee these days. Debt is higher, reimbursement is lower. I certainly know of solo practices who have gone under. Sure, if you are willing to go to a less desirable location, good for you, but is your spouse? Do you have other family concerns regarding your location? The tone of your post is frankly a little arrogant. If money is absolutely the only concern you have, then your decision-making process is probably a little easier and you are more likely to succeed on your own. If you have other considerations, then it's not so cut-and-dried. Good luck to you in whatever direction you choose - just realize that things don't always go exactly according to plan.

 

[KHE]

Times have changed. You can start a practice, but you will need financing (unless you are wealthy, and don't need to borrow for startup costs). Coming to the table with large net negative equity leaves you at a disadvantage if you can even get a loan. Most banks want to see you put something up to secure their money. Many new grads don't have any assets to do this.

In the good old days, before my time, the break-even point was low. Educational debts were low, living costs were much lower than today, office operating costs were lower and third-party payment was huge. You could be in the black on one or two cataract surgeries a week. After that, there was no looking back.

It was a sure thing to buy or launch a practice back then. Not so now. The break-even point is much higher and banks and other lenders are well aware of how the calculus has changed.


Overserved markets have always paid worse. The break-even point was always higher there.


Borrowing $500K isn't as easy as you think unless you or someone is able to put up a large equity stake as collateral, as in their house or a decent size deposit account or a stock portfolio. Having an M.D. and a desirable residency behind you, even with great credit, does not make for automatic easy lending.

I don't agree with this. I've helped two ophthalmologists start practices in the last 3 years and one of them was making money after less than a year and the second is only been open for about 6 months but is on pace to do the same.

You do not have to borrow anywhere near $500k. Both practices that I helped set up got going for less than $100k. Yes, all the equipment was leased and there was no EMR to start with but it was a functioning clinic with some ancillary testing ability.

The keys in both cases were:

1) Keep start up costs low. Don't spend a bunch of money on things like EMRs, autorefractors, the latest and greatest IOL master. It's much easier to add those things as the practice starts to make money. It's much more difficult to get out from under the weight of a large note if you go for too much too soon.

2) Keep staff costs as low as possible. Yes, this means you might have to check your own VAs, do your own Goldmanns etc. etc. for the first year or two. But who cares? No need to waste a bunch of money on assistants, techs and scribes for a start up.

3) Let's be really honest with ourselves. Most ophthalmologists out there are basically dickheads. I'm not saying that because I'm an optometrist or to be inflammatory. I'm saying that if you aren't a dickhead, you can EASILY cultivate good strong referral relationships with primary care/internal medicine in your area because believe me, those docs are tired of dealing with the majority of ophthalmologists who are already there who are almost always by and large, dickheads.

Someone on here once said that the three keys to success are the three As. Affordability, Availability, Affability. I strongly agree with that.

 

[orbitsurgMD]

I don't agree with this. I've helped two ophthalmologists start practices in the last 3 years and one of them was making money after less than a year and the second is only been open for about 6 months but is on pace to do the same.

You do not have to borrow anywhere near $500k. Both practices that I helped set up got going for less than $100k. Yes, all the equipment was leased and there was no EMR to start with but it was a functioning clinic with some ancillary testing ability.

The keys in both cases were:

1) Keep start up costs low. Don't spend a bunch of money on things like EMRs, autorefractors, the latest and greatest IOL master. It's much easier to add those things as the practice starts to make money. It's much more difficult to get out from under the weight of a large note if you go for too much too soon.

2) Keep staff costs as low as possible. Yes, this means you might have to check your own VAs, do your own Goldmanns etc. etc. for the first year or two. But who cares? No need to waste a bunch of money on assistants, techs and scribes for a start up.

3) Let's be really honest with ourselves. Most ophthalmologists out there are basically dickheads. I'm not saying that because I'm an optometrist or to be inflammatory. I'm saying that if you aren't a dickhead, you can EASILY cultivate good strong referral relationships with primary care/internal medicine in your area because believe me, those docs are tired of dealing with the majority of ophthalmologists who are already there who are almost always by and large, dickheads.

Someone on here once said that the three keys to success are the three As. Affordability, Availability, Affability. I strongly agree with that.

I think the $500K figure came from another poster who was estimating the startup costs in a few years as a retina surgeon. I would agree that you might not need quite as much as that, even as a retina surgeon, but you will need more than the minimum amounts of used/leased items you listed and it will cost more than $100K.

No, you don't need a tech or an autorefractor, unless you plan to use the latter also for topography (new ones), or a keratometer (new and not so new ones). I happen to think autorefractors are valuable tools, especially for the ophthalmologist planning on opening staff-lite. the key thing is finding a good used one. They cost a small fraction of what new refractor/wavefront topo/keratometers cost.

You don't need scribes either. A tech is helpful, though. You can extend your capabilities significantly with only one.

A retina doc does need a digital camera with an angio setup, an OCT, a B-mode ultrasound and a couple of functioning lanes, and an argon or diode laser for photocoagulation. He also needs a sterilizer and small supplies inventory for doing intravitreal injections. Then he needs the usual office items, a small network to link his camera to a laser room, extra displays, phone system, office furniture, alarm system, refrigerators, and whatever is needed for buildout. Then he needs startup capital for advertising and operations. I figure at least $250K, but not $500K, unless you are doing significant buildout, but not $100K either.

 

[DOCTORSAIB]

Do you have other family concerns regarding your location? The tone of your post is frankly a little arrogant. If money is absolutely the only concern you have, then your decision-making process is probably a little easier and you are more likely to succeed on your own. If you have other considerations, then it's not so cut-and-dried. Good luck to you in whatever direction you choose - just realize that things don't always go exactly according to plan.

Doc, I think you're misinterpreting my ambition for arrogance. My apologies if my post came across that way.

And as for the 500K number, I highballed it for the sake of the argument. Ideally, I'd like to start out 50/50 with another retina guy -- someone I know well. Then build from there and expand. But that's not for some time!

 

[eyehope]

Doubtful. GI and Cards specialists don't like middle-of-the night work any more than anyone else. That is why many are starting specialist hospitals and endoscopy clinics independent of hospitals, just to avoid the middle-of -the-night requests that, not only are inconvenient but often go unpaid.

once again you bring up the same argument, I do not think that you can consider NJ a remote area, or Florida , but that is beside the point, I have a friend who is a GI fellow who signed up for one of those 500K jobs, he likes the money but the group that hired him told RIGHT OFF THE BAT to expect to be called in to the hospital that they would cover almost half to 75 % of the time he is on call.

There are certainly some areas of Florida that are remote (panhandle) - they always have vacancies. If, according to your original post, you don't mind living in the middle of nowhere, sure, you can make close to 200k starting. But, for those with family/children/spouses, you have to sacrifice a little.

bottom line is this ........

work your ***** off you will make money, Gas or Rads may do less physical work, but they spends the same time ( 12 hour days ) non the less if they want to make the big bucks......

I will go back to my original point :

do what you like and spend more time spending what you have rather than spending more time trying to place yourself in a higher tax bracket and losing almost half of what you will make in taxes.

Every job will become routine. The other ROAD specialties pay much better to start and have the same lifestyle. I don't know about you, but I would rather pay 40-45% of 300k than 35-40% of 125k.

also when someone speaks of those predatory senior ophthalmologist, if they are able to let go of 150 K a year; they have to be making more than that or else they would keep it to themselves, AKA at some point we will get to that point as ophthalmologists, we just need to be patient.

the problem is that you never get the chance with these groups. you can sign a year or two contract with the promise of partnership, build up a decent size practice, and be let go.

regardless of what anyone says, senior partners will always benefit financially from a new associate. Though it may take 3-5 years to build a thriving practice, the senior partners make money off the new associate starting from year one. Make no mistake about it. Then, after the obligatory two years of associate level pay, you end up paying a 5-6 year buy-in (unless you are independently wealthy). They make even more money off you, just like a pyramid scheme. From their standpoint, why see 80 patients/day and be in clinic until 7-730pm when they can bring in an associate and collect off the new guy. Maybe, I am too pessimistic.

but I do understand the frustration of not being able to be well compensated right off the bat as other specialties do, but on the other hand we do not start off with as many cases as they do, I think you yourself mentioned that it takes a whole year for a starting ophthalmologist to build the pt base to cover the costs of him starting out.

I do not see how this is ophthalmology specific. New hires in other lifestyle specialties have to build their practice as well (with radiology/anesthesia as exceptions).

It is not pretty out there for general ophthalmologists in many areas. Since cataract surgery is such a large draw on Medicare expenditures, we are looking at further cuts for surgery reimbursement. Third party insurance companies are negotiating insane rates for eye exams (some less than $50 for a comprehensive exam). Patients will try to lowball, deny, bargain, question your services to zero compensation - because they think we are rolling in cash or because they think we should be completely altruistic. We compete somewhat with optometrists, who outnumber us by a good margin. It may only be a matter of time before more physicians go to a cash only practice. Some internists have offered patients unlimited care for a set fee/year. If you get enough patients to sign up, you can do well without dealing with insurances/billing. But, this is tougher to do with ophthalmology where most patients come in only once or twice a year. I am still waiting to see the explosion of eyecare needed from baby boomers.

Do not be fooled by the salary surveys for ophthalmologists. In most cases, it will take a long time to reach those salaries - at least 5-7 years after you join a practice (because of the required 2 years of non-partnership and the length of the buy-in). Add that the extra 8 years of post-college work, and that is your definition of delayed gratification.

I freely admit that I am somewhat bitter even though I love what I do. I was naive to think ophthalmology was the only specialty for me. Every job will become routine or mundane. We definitely are not hurting, but for those with a ton of educational debt and family, 125k is not a lot of money (esp when you compare to other fields of medicine or outside of medicine). It would be different if you had no loans or family to support. I feel for the primary care physicians starting under 100k. I am sure someone will mention that my salary is still greater than 95% of the population, but 95% of the population did not choose to go through the stressful, sleep-depriving, costly, humbling (and sometimes - well, a lot of times humiliating) experience of medical school and post-grad studies during a prime time in their lives. And, I am sure some will think of me as an elitist, money-grubbing fool.

For those in medical school, take a second look at other specialties. Some may have fewer frustrations - though I guess the "grass is always greener." For those in residency, I suggest subspecialization if you are on the fence or looking into starting your own practice. Become knowledgeable in insurance, Medicare, billing, licensure, and business. You need a lot of forethought, planning, hard work, and patience to start your own practice. I may look into that option if things do not work out here as expected. But, I definitely feel more comfortable about starting my practice now than cold turkey after residency. For those starting out, hang in there (I'm trying). I hope to post more on this forum because we don't get the reality of life after residency during our education. Who knows, things may be different in a year or two or three - I can certainly hope.

 

[Eyefixer]

I completely agree with your points. It's amazing how just 8 months after finishing residency your prospective changes; I don't know about you, but during training I always thought I'd find a sweet old guy who would pass on his practice to me for little money, etc., etc. Now I understand that this is one in a million.

In addition, I think its a very BAD time to start a new practice, ophthalmology or not. There are sweeping changes coming down the Obama pipeline in regards to medicine and no one really knows how this will turn out for us. You don't want to spend 5-6 years buying into a practice just to find out you are now working for the government.

And for people who think "I will go anywhere to make 500K", wait until you get married and/or have kids. You will change your mind, trust me. There are no "new unexplored medical frontiers" in the US. If a place is in away livable, it had been scouted by HMOs, large group, single practitioners, etc.

Sorry to paint a bleak picture. It is what it is.

There are certainly some areas of Florida that are remote (panhandle) - they always have vacancies. If, according to your original post, you don't mind living in the middle of nowhere, sure, you can make close to 200k starting. But, for those with family/children/spouses, you have to sacrifice a little.




Every job will become routine. The other ROAD specialties pay much better to start and have the same lifestyle. I don't know about you, but I would rather pay 40-45% of 300k than 35-40% of 125k.



the problem is that you never get the chance with these groups. you can sign a year or two contract with the promise of partnership, build up a decent size practice, and be let go.

regardless of what anyone says, senior partners will always benefit financially from a new associate. Though it may take 3-5 years to build a thriving practice, the senior partners make money off the new associate starting from year one. Make no mistake about it. Then, after the obligatory two years of associate level pay, you end up paying a 5-6 year buy-in (unless you are independently wealthy). They make even more money off you, just like a pyramid scheme. From their standpoint, why see 80 patients/day and be in clinic until 7-730pm when they can bring in an associate and collect off the new guy. Maybe, I am too pessimistic.



I do not see how this is ophthalmology specific. New hires in other lifestyle specialties have to build their practice as well (with radiology/anesthesia as exceptions).

It is not pretty out there for general ophthalmologists in many areas. Since cataract surgery is such a large draw on Medicare expenditures, we are looking at further cuts for surgery reimbursement. Third party insurance companies are negotiating insane rates for eye exams (some less than $50 for a comprehensive exam). Patients will try to lowball, deny, bargain, question your services to zero compensation - because they think we are rolling in cash or because they think we should be completely altruistic. We compete somewhat with optometrists, who outnumber us by a good margin. It may only be a matter of time before more physicians go to a cash only practice. Some internists have offered patients unlimited care for a set fee/year. If you get enough patients to sign up, you can do well without dealing with insurances/billing. But, this is tougher to do with ophthalmology where most patients come in only once or twice a year. I am still waiting to see the explosion of eyecare needed from baby boomers.

Do not be fooled by the salary surveys for ophthalmologists. In most cases, it will take a long time to reach those salaries - at least 5-7 years after you join a practice (because of the required 2 years of non-partnership and the length of the buy-in). Add that the extra 8 years of post-college work, and that is your definition of delayed gratification.

I freely admit that I am somewhat bitter even though I love what I do. I was naive to think ophthalmology was the only specialty for me. Every job will become routine or mundane. We definitely are not hurting, but for those with a ton of educational debt and family, 125k is not a lot of money (esp when you compare to other fields of medicine or outside of medicine). It would be different if you had no loans or family to support. I feel for the primary care physicians starting under 100k. I am sure someone will mention that my salary is still greater than 95% of the population, but 95% of the population did not choose to go through the stressful, sleep-depriving, costly, humbling (and sometimes - well, a lot of times humiliating) experience of medical school and post-grad studies during a prime time in their lives. And, I am sure some will think of me as an elitist, money-grubbing fool.

For those in medical school, take a second look at other specialties. Some may have fewer frustrations - though I guess the "grass is always greener." For those in residency, I suggest subspecialization if you are on the fence or looking into starting your own practice. Become knowledgeable in insurance, Medicare, billing, licensure, and business. You need a lot of forethought, planning, hard work, and patience to start your own practice. I may look into that option if things do not work out here as expected. But, I definitely feel more comfortable about starting my practice now than cold turkey after residency. For those starting out, hang in there (I'm trying). I hope to post more on this forum because we don't get the reality of life after residency during our education. Who knows, things may be different in a year or two or three - I can certainly hope.

 

[happy optho]

I am really sorry to hear someone discredit a whole specialty just because they have had a bad experience, if you spend more time trying to live in the real world than generalize your own experience

 

[Eyefixer]

If you don not like to hear the answers, do not ask for advice. As a medical student, you really have no idea about the real world. Good luck to you; you are going to need it.

I am really sorry to hear someone discredit a whole specialty just because they have had a bad experience, if you spend more time trying to live in the real world than generalize your own experience

 

[eyehope]

I am really sorry to hear someone discredit a whole specialty just because they have had a bad experience, if you spend more time trying to live in the real world than generalize your own experience

Hey man, I was just trying to help and give some advice (that I wish I would have had years ago). I love the field but it is nothing like I had imagined. If you don't believe the salaries, look at the AAO's website for starting grads (there is an article somewhere). If you don't believe my comments about insurance companies, competition, government reimbursement, just wait. If you don't believe my thoughts on these 'older guys' fleecing the youngin', just beware. My experience is not unique and it is obvious that I am not the only one feeling this way.

If you think you know what the real world is like, why did you even bother posting here? One day, you won't be so defensive about this 'awesome' specialty. It is just a job and it has goods and bads - just like any other job.

 

[HTxFrog]

That is really great insight. That one guy may not like what he hears, but just know there are other people reading these forums that appreciate honesty. I don't know if I am just looking in the wrong places, but it is really hard to find out the true story about what all the different fields are really like when you are finally done. I'm just finishing my MS1 year, so I've got a little time to figure things out, but you really are doing a service to younger guys like me by being honest about things. In this profession, we have to make a decision about what we are going to do for the rest of our lives before we really even know what it is going to be like, and there really isn't any going back after you make that choice. There are downsides to every specialty obviously, and there are a ton of great things that draw me to ophthalmology, but most people would be flat out lying if they told you that the supposed combination of lifestyle and compensation wasn't a big draw for ophtho. If the compensation isn't there as much any more, well that isn't everything, but its definitely something that we should know up front and be ready for. Anyways, I have a final tomorrow so I need to stop procrastinating, but thanks.

 

[CuriousKat]

The question to the person stating a collegue offered a starting salary of 150,000. Was that academic or private?

-JA

I believe it was private multi(sub)specialty group with other ophthalmology subspecialties. I think they lowballed him initially with an offer of like 100K! but he was able to negotiate upwards.

It seems like most midsize to large cities are difficult to get into regardless of specialty.

 

[KHE]

I believe it was private multi(sub)specialty group with other ophthalmology subspecialties. I think they lowballed him initially with an offer of like 100K! but he was able to negotiate upwards.

It seems like most midsize to large cities are difficult to get into regardless of specialty.

On some level, it's good to know that young ophthalmologists bitch and moan about the same things that young optometrists bitch and moan about yet on another it's quite depressing.

After having helped 3 ODs and now two ophthalmologists set up and/or purchase practices, I'm slowly forming a consulting business. Nothing major, I don't intend on leaving clinical practice or practice ownership but I would like to point out a few things and offer up some admittedly unsolicited advice.

Readings posts on this and other forums, it's clear that too many of you fall into the same trap....that being that you think that by finishing your residency or your training that you have "arrived."

And to be fair, I can't really blame you. I understand where it comes from and I was likely guilty of it myself when I first got out of school.

Many of you likely went through the same cycle again and again since high school. "Wow...if I just study really hard and get into a good college, everything will be fine."

Then you get to college...."Wow...if I just study really hard and get into a good medical school, everything will be fine."

Then you make it to medical school...."Wow...if I just study really hard, I'll get into that ophthalmology residency and everything will be fine."

Then you make it through a difficult residency and you think "ok, now someone pay me."

I understand why people think that way but rightly or wrongly, fairly or unfairly, the world doesn't work that way. Being smart and having a unique skill set doesn't automatically mean that someone is going to shower you with lucrative job offers and high salaries and even if they do, you have to sustain it.

You have to switch your attitudes. Like it or not, private practice is about making money, preferably lots of it. Mine and my partner's practice is a multi-million dollar affair. How did we get to this level?

Well, you have to have an attitude of being willing to do whatever it takes. As a young doctor/associate, are you willing to pound the pavement visiting internal medicine or optometry to drum up referrals or are you expecting to come into a situation and be immediately provided with a full schedule?

Are you willing to see that emergency abrasion at the end of the morning who might cut into your lunch hour or that flashes/floaters patient who wants to come in at 4:55 and make you stay late or do you want to be the high-and-mighty doctor and make the public wait for YOU?

Well, understand that those two patients can generate between $100 and $200 for that visit depending on whether photography/extended ophthalmoscopy or other ancillary testing is required. That $100 or $200 pays for one of your techs or your secretary for the day.

And that's how you have to think about it. You don't have to be a pig about money. In our practice, we do plenty of charity work and we don't try to wring every possible nickel out of every possible patient. Yet at the same time, this isn't a hobby and it's not a non-profit venture.

So I would recommend that every young doctor/associate enter any situation with the attitude of "what can I do to make as much money for this clinic/doctor as I possibly can?"

Now, are there predatory practices out there? Of coure...we have them in optometry too. However, even if a partnership doesn't materialize you will have developed the attitude and the skill set needed to be successful and to either start a practice on your own or bring that skill set to a less predatory practice. And the best part of it, any mistakes that you make (and you will make plenty) will come on someone ELSE'S dime.

Another poster on here said that 8 months out they had a change of perspective, and painted a somewhat bleak picture. IMHO, that's way too early to have that type of attitude. Respectfully, that sounds like someone who likely couldn't find their dream situation right off the bat or had a negative experience with their first gig out of school.

And while I certainly don't know anything about that poster or their situation, if I had to bet I would say that that is likely someone (like many ophthalmolgists) who was very likely a very high achiever all through high school, college, med school, residency etc. etc. Makes sense right? To be admitted to ophthalmology you have to be an uber high achiever. Well, it sounds like this might be the first time in their lives that something major didn't quite go as planned. 8 months out is way to early to be negative.

Another poster reported of practices where after two years of associate pay, they are expected to "buy-in" to a practice all the while the senior partners don't take the crappy hours or the call and continue to make money of the young associate. Well.......DUUUHHHH!! Welcome to capitalism in the USA.

Surely you didn't think that after two years of being an associate that the senior partners were just going to cut you a nice big fat slice of cake did you? Of COURSE you have to buy in and of COURSE they're going to make money off you! That's the whole POINT of this. But what does that mean? It means that after 7-8 years, you're a full partner too! And then YOU get to make the big bucks for the rest of your career and hopefully your business grows and expands so that YOU can then hire the eager young go-getter and make money off of THEM.

It's ok to bitch and moan on a forum like this. It can be a good place to vent and blow off some steam. But don't get dragged down into the muck of negativity because that will sink your career faster than any health care reform or malpractice lawyer ever could.

Everyone on here is obviously bright and creative or they wouldn't have made it this far. But don't fall into the trap of thinking that you're at the end of the road. You're not.....in fact, you're on the verge of being able to reap the rewards for all that hard work you've done. Don't drop the ball now!

If you want to be a partner in a group, think.......what can I do to make as much money as possible for this practice?

 

[EyeMD116]

Thanks so much for your post, it is very enlightening and right on the money.

On some level, it's good to know that young ophthalmologists bitch and moan about the same things that young optometrists bitch and moan about yet on another it's quite depressing.

After having helped 3 ODs and now two ophthalmologists set up and/or purchase practices, I'm slowly forming a consulting business. Nothing major, I don't intend on leaving clinical practice or practice ownership but I would like to point out a few things and offer up some admittedly unsolicited advice.

Readings posts on this and other forums, it's clear that too many of you fall into the same trap....that being that you think that by finishing your residency or your training that you have "arrived."

And to be fair, I can't really blame you. I understand where it comes from and I was likely guilty of it myself when I first got out of school.

Many of you likely went through the same cycle again and again since high school. "Wow...if I just study really hard and get into a good college, everything will be fine."

Then you get to college...."Wow...if I just study really hard and get into a good medical school, everything will be fine."

Then you make it to medical school...."Wow...if I just study really hard, I'll get into that ophthalmology residency and everything will be fine."

Then you make it through a difficult residency and you think "ok, now someone pay me."

I understand why people think that way but rightly or wrongly, fairly or unfairly, the world doesn't work that way. Being smart and having a unique skill set doesn't automatically mean that someone is going to shower you with lucrative job offers and high salaries and even if they do, you have to sustain it.

You have to switch your attitudes. Like it or not, private practice is about making money, preferably lots of it. Mine and my partner's practice is a multi-million dollar affair. How did we get to this level?

Well, you have to have an attitude of being willing to do whatever it takes. As a young doctor/associate, are you willing to pound the pavement visiting internal medicine or optometry to drum up referrals or are you expecting to come into a situation and be immediately provided with a full schedule?

Are you willing to see that emergency abrasion at the end of the morning who might cut into your lunch hour or that flashes/floaters patient who wants to come in at 4:55 and make you stay late or do you want to be the high-and-mighty doctor and make the public wait for YOU?

Well, understand that those two patients can generate between $100 and $200 for that visit depending on whether photography/extended ophthalmoscopy or other ancillary testing is required. That $100 or $200 pays for one of your techs or your secretary for the day.

And that's how you have to think about it. You don't have to be a pig about money. In our practice, we do plenty of charity work and we don't try to wring every possible nickel out of every possible patient. Yet at the same time, this isn't a hobby and it's not a non-profit venture.

So I would recommend that every young doctor/associate enter any situation with the attitude of "what can I do to make as much money for this clinic/doctor as I possibly can?"

Now, are there predatory practices out there? Of coure...we have them in optometry too. However, even if a partnership doesn't materialize you will have developed the attitude and the skill set needed to be successful and to either start a practice on your own or bring that skill set to a less predatory practice. And the best part of it, any mistakes that you make (and you will make plenty) will come on someone ELSE'S dime.

Another poster on here said that 8 months out they had a change of perspective, and painted a somewhat bleak picture. IMHO, that's way too early to have that type of attitude. Respectfully, that sounds like someone who likely couldn't find their dream situation right off the bat or had a negative experience with their first gig out of school.

And while I certainly don't know anything about that poster or their situation, if I had to bet I would say that that is likely someone (like many ophthalmolgists) who was very likely a very high achiever all through high school, college, med school, residency etc. etc. Makes sense right? To be admitted to ophthalmology you have to be an uber high achiever. Well, it sounds like this might be the first time in their lives that something major didn't quite go as planned. 8 months out is way to early to be negative.

Another poster reported of practices where after two years of associate pay, they are expected to "buy-in" to a practice all the while the senior partners don't take the crappy hours or the call and continue to make money of the young associate. Well.......DUUUHHHH!! Welcome to capitalism in the USA.

Surely you didn't think that after two years of being an associate that the senior partners were just going to cut you a nice big fat slice of cake did you? Of COURSE you have to buy in and of COURSE they're going to make money off you! That's the whole POINT of this. But what does that mean? It means that after 7-8 years, you're a full partner too! And then YOU get to make the big bucks for the rest of your career and hopefully your business grows and expands so that YOU can then hire the eager young go-getter and make money off of THEM.

It's ok to bitch and moan on a forum like this. It can be a good place to vent and blow off some steam. But don't get dragged down into the muck of negativity because that will sink your career faster than any health care reform or malpractice lawyer ever could.

Everyone on here is obviously bright and creative or they wouldn't have made it this far. But don't fall into the trap of thinking that you're at the end of the road. You're not.....in fact, you're on the verge of being able to reap the rewards for all that hard work you've done. Don't drop the ball now!

If you want to be a partner in a group, think.......what can I do to make as much money as possible for this practice?

 

[Ophtho24]

Thanks for everyones' posts on here. I am in my residency training now, and sometimes I think if I could just magically become a great surgeon without logging tons of cases I would do great when I am done. Unfortunately, becoming a good surgeon takes work and time and as you guys have all pointed out, making money in this field takes work and time. I am sure I will run into many frustrations when I go out and start working and it is good to know that I won't be the only one. I used to think I could start my own practice and recently having talked to other ophthalmologists have decided that it really isn't feasible in today ophthalmology market. These posts have helped me confirm that this really isn't that feasible and that I would be better off putting time into finding a good practice that I can be willing to stick with for the long haul. Thanks again.

 

[happy optho]

Thank God there is someone with some common sense on this msg board

all the points that were made are valid,

also the starting pay is NOT ALL THAT BAD!!!!

yes the start up of your own practice right off the bat may not be the best thing right off the back

here is the deal, it is a fact that in most ( dare I say all ) residency programms we r NOT trained to CODE, we are not trained how to bill, we R just not trained to become buessnessmen ---> so I would not mind being paid while I am learning and making some mistakes along the way ( some one is paying my malpractice for me and giving me a pt base, so starting off with a normal salary is not bad,

once I have the experience and the buseness saviness ( that only being in practice will provide ) then I will start thinking about how I am being ripped off, when u think about it the practice is also taking a chance on someone who is right off training.

other specialties are the same way in a sense but most have hospitals backing them up, but even then, the workload is much bigger initially than ophathlmology, and the hours are most lilkey worse ( if u want the big bucks ) we just have to wait a little to make the big bucks

 

[eyehope]

Thank you for your post KHE. It puts a lot of things into perspective. You are right that there is some 'bitching and moaning' in my posts.

My buy-in comment was to give an example of the economic reality of our field. Some med students or residents look at salary surveys and expect some level of compensation (and I was one of them) from day 1. But in reality, that compensation may not come for 7-8 years after residency. That is a long time. Rightly or wrongly, a lot of ophthalmology residents worked extremely hard during medical school and probably had a choice of other medical specialties.

Some of these specialties
(1) do not have buy-ins at all
(2) have higher starting salaries (2-2.5x that of general ophthalmologists) from year 1 after residency (not in year seven or eight)
(3) similar lifestyles to ophthalmology

That is why I suggested that some look at other fields - if they were equally interested in them. Or, suggested starting your own practice. Or, going into subspecialties of ophthalmology. Money isn't everything, but it is a pretty important factor for many of us.

 

[DOCTORSAIB]

KHE, I may not have agreed with you in the past on some other topics affecting our respective fields but I couldn't have said what you just said any better.

 

[speyeder]

Thank you for your post KHE. It puts a lot of things into perspective. You are right that there is some 'bitching and moaning' in my posts.

My buy-in comment was to give an example of the economic reality of our field. Some med students or residents look at salary surveys and expect some level of compensation (and I was one of them) from day 1. But in reality, that compensation may not come for 7-8 years after residency. That is a long time. Rightly or wrongly, a lot of ophthalmology residents worked extremely hard during medical school and probably had a choice of other medical specialties.

Some of these specialties
(1) do not have buy-ins at all
(2) have higher starting salaries (2-2.5x that of general ophthalmologists) from year 1 after residency (not in year seven or eight)
(3) similar lifestyles to ophthalmology

That is why I suggested that some look at other fields - if they were equally interested in them. Or, suggested starting your own practice. Or, going into subspecialties of ophthalmology. Money isn't everything, but it is a pretty important factor for many of us.

It is true that some specialties have little to no buy-in and have higher starting salaries. This is because ophthalmology is so equipment and technology driven that our start-up costs and overhead are so much higher. However as you pointed out after several years in practice ophthalmology catches up quickly and may even surpass the salaries of many of these other fields. So in the end it pretty much evens out. The moral of the story is to pick something you love because compensation can change on the whim of our legislators.

 

[DwyaneWade]

This thread is depressing

 

[andwhat]

Doc, I think you're misinterpreting my ambition for arrogance. My apologies if my post came across that way.

And as for the 500K number, I highballed it for the sake of the argument. Ideally, I'd like to start out 50/50 with another retina guy -- someone I know well. Then build from there and expand. But that's not for some time!

point made, you shouldn't chase money

 

[DOCTORSAIB]

point made, you shouldn't chase money

Thank you Captain Obvious.

I'm chasing my dream and that's to be a successful ophthalmologist/entrepreneur.

 

[andwhat]

Thank you Captain Obvious.

I'm chasing my dream and that's to be a successful ophthalmologist/entrepreneur.

You are very much welcome! Apology somewhat accepted.
Don't chase money, otherwise you will be disappointed. Thanks for helping that come to light.

will get you nowhere, but broke and frustrated.

In certain specialties, and careers it is possible however.
You have to love what you do more than anything.
Nice job to help clarify that issue.

 

[KHE]

After I made that posting, I was a bit hesitant. I didn't want people to think that I was lecturing or scolding people.

I'm glad it was well received. Understand that all of you are likey very bright and creative. But outside of an academic environment, that doesn't translate into patients or money.

Someone once posted the three "A"s to success in medicine.....affordability, availability, and affability. I would agree with those strongly.

Interestingly enough, competence, smarts, surgical skill aren't among the keys to success. I'm sure you all know doctors who have very loyal patients and/or very successful practices who are really only mediocre diagnosticians or surgeons. And yet their patients think that they walk on water.

Let's try an exercise...

I get the impression that many posters on here want to be in private practice. That is afterall where the "real" money is.

Let's say hyopthetically that a two doctor general ophthalmolgoy practice and was are in need of an associate. They have enough overflow to fill your schedule 2-3 days a week. One of the doctors is in his late 50s and thinks about retiring over the next 10 years. The other one is in his mid 40s and doesn't antipate retirement for 20-25 years.

How would you handle a situation like that? What would you do for this practice?

 

[orbitsurgMD]

After I made that posting, I was a bit hesitant. I didn't want people to think that I was lecturing or scolding people.

I'm glad it was well received. Understand that all of you are likey very bright and creative. But outside of an academic environment, that doesn't translate into patients or money.

Someone once posted the three "A"s to success in medicine.....affordability, availability, and affability. I would agree with those strongly.

Interestingly enough, competence, smarts, surgical skill aren't among the keys to success. I'm sure you all know doctors who have very loyal patients and/or very successful practices who are really only mediocre diagnosticians or surgeons. And yet their patients think that they walk on water.

Let's try an exercise...

I get the impression that many posters on here want to be in private practice. That is afterall where the "real" money is.

Let's say hyopthetically that a two doctor general ophthalmolgoy practice and was are in need of an associate. They have enough overflow to fill your schedule 2-3 days a week. One of the doctors is in his late 50s and thinks about retiring over the next 10 years. The other one is in his mid 40s and doesn't antipate retirement for 20-25 years.

How would you handle a situation like that? What would you do for this practice?

Do they want a new associate? Or do they just want someone to take up the overflow to keep wait times short? This is important to know.

The first invites many more questions that need answers. The second might be met by a part-time doctor, a younger doctor with children who doesn't want ownership then or full-time work, or someone near retirement who wants to reduce hours and maybe do less surgery, perhaps in exchange for taking less or no call.

Are the partners equal partners? How are significant practice decisions made? Do both seem like the kind of people who will accept a new partner whose presence will leave none of them with a controlling interest in the practice?

What are the facilities like? Are they large enough to accommodate three doctors working at the same time? Will new space be needed to support a new doctor?

 

[KHE]

These are all legitmate questions but I was hoping to focus more on ideas on how a young associate can help to grow a practice.

So let's then assume that it's a two doctor practice with some overflow but not necissarily enough to support a full time associate but that they would like to treat the practice almost like a law firm in that they would like it to grow enough so that partners can be added. In otherwords, there is a potential for partnership there.

So in essence, the question becomes....how can a young associate help grow a practice that has some overflow but doesn't necissarily have enough to support a full time doc right off the bat.

Do they want a new associate? Or do they just want someone to take up the overflow to keep wait times short? This is important to know.

The first invites many more questions that need answers. The second might be met by a part-time doctor, a younger doctor with children who doesn't want ownership then or full-time work, or someone near retirement who wants to reduce hours and maybe do less surgery, perhaps in exchange for taking less or no call.

Are the partners equal partners? How are significant practice decisions made? Do both seem like the kind of people who will accept a new partner whose presence will leave none of them with a controlling interest in the practice?

What are the facilities like? Are they large enough to accommodate three doctors working at the same time? Will new space be needed to support a new doctor?

 

[orbitsurgMD]

. . . . They have enough overflow to fill your schedule 2-3 days a week.

That amount of work should already cover the net added costs to the practice of the new associate. The issue is how to make him full-time busy and thus contribute to the overhead more and possibly earn himself bonus money.

Consider a subspecialty-trained doctor who wants to continue with some general work in his practice for an indefinite period, possibly permanently.

Market to the present referral base. Optometrists, internists, family medicine doctors, local nurse practitioners.

Consider a satellite location, possibly paying local optometrists to use excess space as available.

Approach a hospital and ask if they want to sponsor an eye clinic, make space available, etc.

Approach a VA hospital and inquire if they need a part-time staff doctor to cover their clinic.

Advertise.

 

[DOCTORSAIB]

These are all legitmate questions but I was hoping to focus more on ideas on how a young associate can help to grow a practice.

So let's then assume that it's a two doctor practice with some overflow but not necissarily enough to support a full time associate but that they would like to treat the practice almost like a law firm in that they would like it to grow enough so that partners can be added. In otherwords, there is a potential for partnership there.

So in essence, the question becomes....how can a young associate help grow a practice that has some overflow but doesn't necissarily have enough to support a full time doc right off the bat.

I'll bite. You have to sell yourself as an asset to the practice. In other words what skills do you bring to the table? Clearly I'm not just talking about your ophtho skills. We all have that at that point.

Here's how I would sell myself:

1) I'm young, hungry and reliable. I'm ready to work. I'm willing to stay late. I'll cover more call if need be. You paid your dues, now it's time to pay mine. It's no different than residency. The more you progress, the less crap you put up with. But until then, do what you gotta do and smile while you're doing it. Most of all, don't whine.

2) If I'm going to join your practice I will do it ONLY IF I can treat it as my own. Afterall, business is about building relationships, not short term gains (Read "7 Habits of Highly Effective People" for more on this!). To that extent, I will market myself and recruit patients to the best of my abilities for your practice. If that means going from door to door of PCPs/optometrists to market myself, so be it. If I have to go to networking events, social mixers, etc to sell my/your practice, so be it. Whatever it takes, you will find me profitable. Gauranteed.

3) I have always been business minded. When I drive through a neighborhood I think "What kind of business would thrive here? Is there a need that is not currently met?" Similarily, during my job interview heres what I would say -- "I did some research for this area (the area of the practice you're interviewing for) and I've discovered that "x, y, z" is needed and your practice doesn't offer it yet." This goes back to my point, what are YOU (the interviewee) going to be bring to the table on interview? I could go on and on about this. But you guys get the point.

4) And during residency, my primary job is to learn my craft and be excellent at it. My other job (and not written any residency contract) is to network and learn procedures and skills that "pay." The more of these I have under my belt, the more marketable I will be when I interview for jobs. These include any lasers, injections, cosmetic procedures, etc. Learn, learn, learn. Be damn good at what you do. Then make it happen.

I have a few more thoughts but I'll stop here. KHE, I hope I'm not too off tangent with my answer.

 

[orbitsurgMD]

That amount of work should already cover the net added costs to the practice of the new associate. The issue is how to make him full-time busy and thus contribute to the overhead more and possibly earn himself bonus money.

Consider a subspecialty-trained doctor who wants to continue with some general work in his practice for an indefinite period, possibly permanently.

Market to the present referral base. Optometrists, internists, family medicine doctors, local nurse practitioners.

Consider a satellite location, possibly paying local optometrists to use excess space as available.

Approach a hospital and ask if they want to sponsor an eye clinic, make space available, etc.

Approach a VA hospital and inquire if they need a part-time staff doctor to cover their clinic.

Advertise.

I would add one more thing: I would structure compensation so that the new hire got a percentage of every dollar he brought in as a bonus, from the first dollar onward. The percentage should be progressive, getting larger as certain amounts of collections are obtained. The rate and rate of increase could be adjusted year-to year until the new hire was basically working on straight percentage with no guarantee.

There is a strong incentive to produce when you know you will see more money in your check for seeing an extra two add-on patients at the end of the day, as opposed to the vague concept of maybe seeing a bonus sometime that year if your collections exceed some hard-to conceive threshhold of collections. With a threshhold of zero, the incentive is here and now.

 

[KHE]

That amount of work should already cover the net added costs to the practice of the new associate. The issue is how to make him full-time busy and thus contribute to the overhead more and possibly earn himself bonus money.

Consider a subspecialty-trained doctor who wants to continue with some general work in his practice for an indefinite period, possibly permanently.

Market to the present referral base. Optometrists, internists, family medicine doctors, local nurse practitioners.

Consider a satellite location, possibly paying local optometrists to use excess space as available.

Approach a hospital and ask if they want to sponsor an eye clinic, make space available, etc.

Approach a VA hospital and inquire if they need a part-time staff doctor to cover their clinic.

Advertise.

Some of those things are things that really the owner of the practice would have to do. Others could be done by the new associate. The question really wasn't "what can the owner do" the question was "what can the young associate do to bring in more money to the practice and grow the business?"

Some of those are great suggestions for a young associate.

 

[KHE]

I'll bite. You have to sell yourself as an asset to the practice. In other words what skills do you bring to the table? Clearly I'm not just talking about your ophtho skills. We all have that at that point.

Here's how I would sell myself:

1) I'm young, hungry and reliable. I'm ready to work. I'm willing to stay late. I'll cover more call if need be. You paid your dues, now it's time to pay mine. It's no different than residency. The more you progress, the less crap you put up with. But until then, do what you gotta do and smile while you're doing it. Most of all, don't whine.

2) If I'm going to join your practice I will do it ONLY IF I can treat it as my own. Afterall, business is about building relationships, not short term gains (Read "7 Habits of Highly Effective People" for more on this!). To that extent, I will market myself and recruit patients to the best of my abilities for your practice. If that means going from door to door of PCPs/optometrists to market myself, so be it. If I have to go to networking events, social mixers, etc to sell my/your practice, so be it. Whatever it takes, you will find me profitable. Gauranteed.

3) I have always been business minded. When I drive through a neighborhood I think "What kind of business would thrive here? Is there a need that is not currently met?" Similarily, during my job interview heres what I would say -- "I did some research for this area (the area of the practice you're interviewing for) and I've discovered that "x, y, z" is needed and your practice doesn't offer it yet." This goes back to my point, what are YOU (the interviewee) going to be bring to the table on interview? I could go on and on about this. But you guys get the point.

4) And during residency, my primary job is to learn my craft and be excellent at it. My other job (and not written any residency contract) is to network and learn procedures and skills that "pay." The more of these I have under my belt, the more marketable I will be when I interview for jobs. These include any lasers, injections, cosmetic procedures, etc. Learn, learn, learn. Be damn good at what you do. Then make it happen.

I have a few more thoughts but I'll stop here. KHE, I hope I'm not too off tangent with my answer.

These are all good things, but many of them are somewhat philosophical in nature and not so concrete with the exception of number 2. Number 2 has actuall things you can DO rather than something like "learn, learn, learn." Learn, learn, learn is great but in what way are you going to make that translate into actual dollars?

 

[DOCTORSAIB]

These are all good things, but many of them are somewhat philosophical in nature and not so concrete with the exception of number 2. Number 2 has actuall things you can DO rather than something like "learn, learn, learn." Learn, learn, learn is great but in what way are you going to make that translate into actual dollars?

You learn as many procedures as you can esp ones that pay. Then when you join a practice, you see what they don't offer that is profitable. If that means Botox, Juvederm, etc, then fine, start advertising cosmetics. Offer 1-2 services at first, market, get the people in the door. Then add more and more procedures as time goes on. If it pays, keep it. If it doesn't, lose it. Being successful is about evolving and adapting.

So philosophically, you're adding new energy to the practice.

Practically, you're adding procedures/services that didn't exist before and you're taking it upon yourself to be creative at marketing it. Get them to come for one service then up-sell your other services.

KHE, what are your thoughts on this? You have a lot of experience in running a successful PP. I should be listening to you!

 

[eyehope]

You learn as many procedures as you can esp ones that pay. Then when you join a practice, you see what they don't offer that is profitable. If that means Botox, Juvederm, etc, then fine, start advertising cosmetics. Offer 1-2 services at first, market, get the people in the door. Then add more and more procedures as time goes on. If it pays, keep it. If it doesn't, lose it. Being successful is about evolving and adapting.

So philosophically, you're adding new energy to the practice.

Practically, you're adding procedures/services that didn't exist before and you're taking it upon yourself to be creative at marketing it. Get them to come for one service then up-sell your other services.

KHE, what are your thoughts on this? You have a lot of experience in running a successful PP. I should be listening to you!

I hope you are speaking in generality. If you are really going to be a retina surgeon, no one will refer you any patients if you start duplicating procedures (whether it be cosmetic, surgical, medical) offered by the comprehensive guys.

 

[Eyefixer]

My friend, I respect your enthusiasm, but I have to say you are soooooo naive. You remind me of myself and many others I knew at the start of my residency. Please keep in mind that ophthalmology attracts the best and the brightest and EVERYONE is either just as bright and savvy or brighter and savvier than you . For the most part in most livable areas most things have been tried and done. If there is an community undeserved in retina, a big retina group already opened a sattelite or two there. If there are multiple optoms in the area, each one is being pestered by a new ophthalmologist every week. Most internal/family docs instruct their secretaries to screen out calls from sub-specialists other than the ones they already work with.

You are going to be a retina surgeon, right? What procedures are you going to offer that are different from all other retina specialists in the area? You are going to mix in some Botox into Avastin for your intravits? You think you are going to be top notch hot shot grade A retinal ace right out of fellowship? Think again. Most people will tell you your training starts AFTER you finish your fellowship. Some retina fellowhips will allow you to finish with 800-1000 vits, but at an average place you'll do 400. That's not nearly enough to function as an top notch retina surgeron right off the bet.

Bringing lots of new energy to a practice is great and your employers will be glad to have you. However, you will not be treated as equal; you can forget that. Moreover, the staff will not treat you as equal; they know who the partners are. You will, however, stay late and have extra call; that's guaranteed.

You learn as many procedures as you can esp ones that pay. Then when you join a practice, you see what they don't offer that is profitable. If that means Botox, Juvederm, etc, then fine, start advertising cosmetics. Offer 1-2 services at first, market, get the people in the door. Then add more and more procedures as time goes on. If it pays, keep it. If it doesn't, lose it. Being successful is about evolving and adapting.

So philosophically, you're adding new energy to the practice.

Practically, you're adding procedures/services that didn't exist before and you're taking it upon yourself to be creative at marketing it. Get them to come for one service then up-sell your other services.

KHE, what are your thoughts on this? You have a lot of experience in running a successful PP. I should be listening to you!

 

[DOCTORSAIB]

I'm not quite sure why there is hostility in this thread towards my ideas. I don't see anyone else offering any (besides orbitsurgMD, who is always helpful).

Yes I was speaking generally. Notice I offered only a few examples of things that can be offered (ie cosmetics). Clearly a retina surgeon is not going to be injecting Botox with Avastin. I mean let's get real here.

Ironically, I'm learning more from an Optometry attending than some of the new grads on here.

 

[orbitsurgMD]

I'm not quite sure why there is hostility in this thread towards my ideas. I don't see anyone else offering any (besides orbitsurgMD, who is always helpful).

Yes I was speaking generally. Notice I offered only a few examples of things that can be offered (ie cosmetics). Clearly a retina surgeon is not going to be injecting Botox with Avastin. I mean let's get real here.

Ironically, I'm learning more from an Optometry attending than some of the new grads on here.

I have to tell you, it won't help your retina practice to be doing Botox or fillers or non-retina procedures. You will have to decide whether you want to be a retina subspecialist who gets referrals for retina problems or a retina-fellowship-trained comprehensive ophthalmologist that doesn't depend on getting many referrals.

And it isn't the oculoplastics doctors who will force you to do one or the other; we are just not that numerous to be a significant influence on the market, small as it is. General/comprehensive ophthalmologists will not be inclined to send you retina work if they think you are poaching in areas of non-retina practice that they might see as their domain, even if they aren't doing those same procedures themselves. That is just the psychology and politics of private practice.

If you want to get generous referrals, you must be attentive to getting the patient back to the refering doctor as soon as it is safe to do so. You want to reinforce the confidence the patient has in the doctor that sent the patient to you. Trying to sell the patient you have successfully treated with an Avastin injection a Botox injection or Restylane filler injection only undermines the relationship you have with your referring doctor, regardless how you might think it "builds" your practice. It helps to say to the patient that they are very fortunate to have such a good and cautious doctor looking after them and that you are always happy to receive patients from that doctor and how you wish all your patients were as well looked after. Tell them you will report the findings fully and that you will always be there for them, but be sure to send that patient back straight away. It might even be beneficial to have your staff call that referring doctor to ask that they schedule a followup with the referring optometrist or general ophthalmologist in three months or so, just to reinforce the point.

If you want a referral practice, you want to avoid the local reputation of your practice being a "black hole", the kind of practice into which a referred patient enters and is never seen or heard from again. That can happen with some academic practices, and it can create a kind of "town-gown" division.

Now if you go somewhere there is no ophthalmology support at all, if there is still such a place, and you want to do both retina and other things, then there will probably no problem building a practice, understanding that you have elected to become a comprehensive ophthalmologist. What you won't likely receive is referrals from any other comprehensive ophthalmologists and, with the diversity of practice becoming known to your community, you may have difficulty breaking into established referral patterns of local optometrists who may have been sending retina work to an academic center.

In retina, you want to project an image of being committed to retina and of offering the very latest treatment options and with better service than the academic centers offer. Personal service and convenience is not usually the long suit of academic centers, institutional brand reputation is what gives them their advantage.