Kaiser ophthalmology?

[Eyefixer]

Does anyone have any information on working as an ophthalmologist at Kaiser Permanente? I do know a few people that do and they seem extremely happy. Any info? Pluses? Minuses?

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[eyehope]

Does anyone have any information on working as an ophthalmologist at Kaiser Permanente? I do know a few people that do and they seem extremely happy. Any info? Pluses? Minuses?

sorry no one has replied yet. i work in private practice so this is not insider information.

pros
1. built-in referral network
2. higher starting salary
3. better health/pension/retirement benefits
4. do not have to worry about billing/insurance (but probably true for most large groups)
5. less busy clinic schedule

cons
1. lower potential income
2. larger organization - dealing with the bureaucracy (esp with hiring/firing of techs)
3. perhaps less flexibility with vacation scheduling (?)
4. no ownership of the practice

 

[Eyefixer]

Thanks for your opinions; pretty much right on the money. With the economy the way it is and where it's going, exploding baby boomer population and no way of paying for it without cutting reimbursements even further, "predatory senior ophthalmology generation" unwilling to cut new guys a break, especially in the desirable areas, I would say that lower earning potential maybe questionable and no ownership in the practice may be a plus. What do you think?

sorry no one has replied yet. i work in private practice so this is not insider information.

pros
1. built-in referral network
2. higher starting salary
3. better health/pension/retirement benefits
4. do not have to worry about billing/insurance (but probably true for most large groups)
5. less busy clinic schedule

cons
1. lower potential income
2. larger organization - dealing with the bureaucracy (esp with hiring/firing of techs)
3. perhaps less flexibility with vacation scheduling (?)
4. no ownership of the practice

 

[eyehope]

Yes, it can be disheartening. I didn't realize how undervalued my services were until recently - it is unfortunate that we do not get more business/billing teaching in residency. You get contracted with insurance companies and have to write off 30-60% of billable fees. Medicare is looking to cut back on reimbursement even more - it is easy for them to slash another 5-10% off cataract reimbursement and 'save' billions. It is incredible how 'cheap' cataract surgery has become, just because it is perceived as a easy, fast surgery - perpetuated by some cataract cowboys who do not even see their own post-ops (or pre-ops for that matter). The surgery would be worth a lot more in the free market when you consider the quality of life improvement.

The market is definitely competitive for desirable areas which drives compensation and benefits down. It is not unheard of to have offers below 100 in these areas. Frustrating. Most senior guys will make money off of you during the buy-in period - which may last 3-5 years.

But, the honest guys are still out there. You just have to do your due diligence before signing a contract. Word gets around about predatory senior guys. Ask the local Alcon, Allergan reps - they know a lot more than most local docs about who has joined/left practices recently.

You may also consider going solo, but need to start in your last year of residency. It took me 7-8 months to get my state license and medicare number. Many insurance companies desire a medicare number before you can get put on their plans. You need to good year to write a business model, secure a loan, buy/lease equipment, read about billing/insurance, and get your licensure. Going solo is a huge pain in the butt and will be rough for a few years (few vacation, being on call all the time, building up a practice), but you get to do everything your way. It can be very rewarding. It is not for everyone - it wasn't for me - at least not right now.

 

[Eyefixer]

I appreciate your input. I like to keep this discussion going; I am just curious what other people think out there.

Without going into too much detail, I have spent about 6 months working per diem in a few places in a very competitive area. I thought about solo, associate, etc. positions. I did start early in residency and was able to get everything squared away by July 1st of my senior year (license, dea, most insurance panels, medicaid, etc.,etc.). I understand that the economy plays a huge part in this and that I probably graduated during the worst possible time (well, residents graduating this year are doing so during the worst possible time ), and here is what I have observed: I witnessed refractive volume drop about 80% in just a few months (evidenced by the volume numbers in the refrective ASC where I had priviliges). That led a lot of local guys who were >50% refractive for the past 15 years pick up more general stuff, lay off some staff, shorten working weeks, etc. That in turn is hurting everyone else. I know a few guys retirement age taking extra clinic days and a few closing up shop. Can a young guy consider buying a practice being closed? Sure, but what are you buying? There is a trend nowdays where practices are way overvalued and everyone knows that including the buyers. How does one calsulate "good will" nowdays?

Moreover, a lot of guys I have spoken with won't even give you a salary. "Well, you come in and I'll just give you precentage of your collections and then we'll see...". B*****t, that's no way to start someone out even though this is the easiest for the practice owner.

All in all, I agree with you. It's amazing how our services are undervalued. Cataract surgery pays around $650 now. According to chats on ASCRS and other forums, $500 is a break point for most people. If it gets less than that, people would stop operating because they can make more money in clinics. And ophthalmology services is projected to have the highest demand jump by 2020 only second to cardiology services.

What I have seen in the last 6 months made me very unsure about private practices nowdays. Don't get me wrong, I think you can still do pretty well if you are willing to skip New York, LA, SF, etc. But if you are not willing to do that, you will find job market tougher than you expect.

Having said all that, Kaiser is starting to look better and better. Even with all the negatives you've listed.

Yes, it can be disheartening. I didn't realize how undervalued my services were until recently - it is unfortunate that we do not get more business/billing teaching in residency. You get contracted with insurance companies and have to write off 30-60% of billable fees. Medicare is looking to cut back on reimbursement even more - it is easy for them to slash another 5-10% off cataract reimbursement and 'save' billions. It is incredible how 'cheap' cataract surgery has become, just because it is perceived as a easy, fast surgery - perpetuated by some cataract cowboys who do not even see their own post-ops (or pre-ops for that matter). The surgery would be worth a lot more in the free market when you consider the quality of life improvement.

The market is definitely competitive for desirable areas which drives compensation and benefits down. It is not unheard of to have offers below 100 in these areas. Frustrating. Most senior guys will make money off of you during the buy-in period - which may last 3-5 years.

But, the honest guys are still out there. You just have to do your due diligence before signing a contract. Word gets around about predatory senior guys. Ask the local Alcon, Allergan reps - they know a lot more than most local docs about who has joined/left practices recently.

You may also consider going solo, but need to start in your last year of residency. It took me 7-8 months to get my state license and medicare number. Many insurance companies desire a medicare number before you can get put on their plans. You need to good year to write a business model, secure a loan, buy/lease equipment, read about billing/insurance, and get your licensure. Going solo is a huge pain in the butt and will be rough for a few years (few vacation, being on call all the time, building up a practice), but you get to do everything your way. It can be very rewarding. It is not for everyone - it wasn't for me - at least not right now.

 

[orbitsurgMD]

I appreciate your input. I like to keep this discussion going; I am just curious what other people think out there.

Without going into too much detail, I have spent about 6 months working per diem in a few places in a very competitive area. I thought about solo, associate, etc. positions. I did start early in residency and was able to get everything squared away by July 1st of my senior year (license, dea, most insurance panels, medicaid, etc.,etc.). I understand that the economy plays a huge part in this and that I probably graduated during the worst possible time (well, residents graduating this year are doing so during the worst possible time ), and here is what I have observed: I witnessed refractive volume drop about 80% in just a few months (evidenced by the volume numbers in the refrective ASC where I had priviliges). That led a lot of local guys who were >50% refractive for the past 15 years pick up more general stuff, lay off some staff, shorten working weeks, etc. That in turn is hurting everyone else. I know a few guys retirement age taking extra clinic days and a few closing up shop. Can a young guy consider buying a practice being closed? Sure, but what are you buying? There is a trend nowdays where practices are way overvalued and everyone knows that including the buyers. How does one calsulate "good will" nowdays?

Moreover, a lot of guys I have spoken with won't even give you a salary. "Well, you come in and I'll just give you precentage of your collections and then we'll see...". B*****t, that's no way to start someone out even though this is the easiest for the practice owner.

All in all, I agree with you. It's amazing how our services are undervalued. Cataract surgery pays around $650 now. According to chats on ASCRS and other forums, $500 is a break point for most people. If it gets less than that, people would stop operating because they can make more money in clinics. And ophthalmology services is projected to have the highest demand jump by 2020 only second to cardiology services.

What I have seen in the last 6 months made me very unsure about private practices nowdays. Don't get me wrong, I think you can still do pretty well if you are willing to skip New York, LA, SF, etc. But if you are not willing to do that, you will find job market tougher than you expect.

Having said all that, Kaiser is starting to look better and better. Even with all the negatives you've listed.

As someone who went first the route of joining groups--and experiencing the true nature of senior predation--and who now is in solo practice, I wouldn't blame you in the least if you wanted to go with a Kaiser or the VA.

Solo private practice can be rewarding, but it has never been riskier in the memory of anyone in practice today, and even under better circumstances, it is very hard work. Think seven days a week and sleepless nights.
Unless you have a large and well-funded organization behind you, like a community hospital recruiting and underwriting your startup, this is a very uncertain time to launch unless you have a valuable and available niche to fill. And even then, there are no guarantees.

I definitely would advise against buying a practice unless you are certain that you can pay it off on your worst-case model. The general trend is declining payment both for service fees and soon, for facility fees. The federal government will not be willing to make surgery center ownership a profitable venture if the choice becomes that or popular but expensive therapies.

 

[DOCTORSAIB]

Not to derail this thread, BUT reading this advice from experienced/practicing ophthalmologists on here is making me a bit worried...

I'll be starting my residency this July and at this point will most likely be pursuing a retina fellowship in a few years. I'm doing this for a few reasons:

1) retina makes serious money (b/c they're in higher demand).
2) I enjoy the pathology and procedures.
3) It allows me to be "in-training" during these volatile times. I think we'll all have a better feel for the market climate once the dust of Obama-nation settles.

These are MY reasons and not necessarily in order of importance..

So my question to you guys is -- does your advice mainly apply to general ophthalmologists? Would a retina specialist face these same issues and to the same extent?

This forum and you guys are indispensable!

 

[eyehope]

IMO, retina will be affected to a lesser extent. There are only about 1500 retina specialist in the US, so their Medicare "pie" is smaller. As a retina guy, you bill a ton in clinic because FAs, OCTs, and lasers reimburse very, very well.

The same predatory senior concerns still apply. Retina seems even more saturated in desirable areas than general ophthalmology. Regardless, if I had to do it over again, I'd subspecialize in retina.

Take my perspective with some doubt. I enjoy what I do. There are a lot of positives of ophthalmology. We enjoy a pretty nice call schedule with few emergencies (sans retina). Normal, outpatient office hours. No dirty work. Our patients are generally healthy. Patients are very grateful after surgery. Opportunity to do lots of good with international medical missions. Cool technology. But, right now, I feel very undervalued. There are daily complaints about refraction fees, exam fees, co-payments. It is incredible the amount of billable we have to write off/eat. Some insurance companies only pay $50 or $60 for a full yearly, dilated exam with refraction. A person paying cash would pay more at Walmart for a less complete exam.

I guess I am bitter when I realize I could have started with 3x the salary in radiology or 2x the salary in many other fields of medicine - no exaggerating. Look at the salary ranges in the AAO's YO section. It is incredible how low starting salaries are compared to other subspecialty (like ENT, derm, rads, anesthesia). In many practices, your salary does not improve much for 4-5 years with the buy-in (if they decide to make you a partner after 2 years). It just does not make sense....

I do not want to appear money hungry, but compensation is definitely a concern. Yes, I realize I am making more than 90% of the population. But, when I realized my potential salary in other fields, it is difficult not to be dishearten. I am sure I will get a lot of flack for my comments but I never claimed to be a saint.

I wish others would post their experiences (good or bad) on here. I wish I would have known about the "real world" because it may have affected my sub/specialty selection.

Maybe I will feel different in 3 or 5 years. I hope so.

Not to derail this thread, BUT reading this advice from experienced/practicing ophthalmologists on here is making me a bit worried...

I'll be starting my residency this July and at this point will most likely be pursuing a retina fellowship in a few years. I'm doing this for a few reasons:

1) retina makes serious money (b/c they're in higher demand).
2) I enjoy the pathology and procedures.
3) It allows me to be "in-training" during these volatile times. I think we'll all have a better feel for the market climate once the dust of Obama-nation settles.

These are MY reasons and not necessarily in order of importance..

So my question to you guys is -- does your advice mainly apply to general ophthalmologists? Would a retina specialist face these same issues and to the same extent?

This forum and you guys are indispensable!

 

[CuriousKat]

Yes, it can be disheartening. I didn't realize how undervalued my services were until recently - it is unfortunate that we do not get more business/billing teaching in residency. You get contracted with insurance companies and have to write off 30-60% of billable fees. Medicare is looking to cut back on reimbursement even more - it is easy for them to slash another 5-10% off cataract reimbursement and 'save' billions. It is incredible how 'cheap' cataract surgery has become, just because it is perceived as a easy, fast surgery - perpetuated by some cataract cowboys who do not even see their own post-ops (or pre-ops for that matter). The surgery would be worth a lot more in the free market when you consider the quality of life improvement.

The market is definitely competitive for desirable areas which drives compensation and benefits down. It is not unheard of to have offers below 100 in these areas. Frustrating. Most senior guys will make money off of you during the buy-in period - which may last 3-5 years.

But, the honest guys are still out there. You just have to do your due diligence before signing a contract. Word gets around about predatory senior guys. Ask the local Alcon, Allergan reps - they know a lot more than most local docs about who has joined/left practices recently.

You may also consider going solo, but need to start in your last year of residency. It took me 7-8 months to get my state license and medicare number. Many insurance companies desire a medicare number before you can get put on their plans. You need to good year to write a business model, secure a loan, buy/lease equipment, read about billing/insurance, and get your licensure. Going solo is a huge pain in the butt and will be rough for a few years (few vacation, being on call all the time, building up a practice), but you get to do everything your way. It can be very rewarding. It is not for everyone - it wasn't for me - at least not right now.

I'm not in ophthalmology but is that really true? Less than 100K? I thought optometrists made about that much. That is ridiculous. Might as well save 4 years and get an OD. And here I thought starting salaries in my field were falling. I apparently have nothing to complain about.

There is an ophtho in the town I grew up in who specializes in cataract surgery. Granted he is probably mid-late career at this point but the guy owns a plane and drives around in a new Maserati. He always seemed a bit out of touch in a small midwestern town populated by middle class blue collar families like mine. I always assumed his wealth was from with ophtho practice but now I'm suspicious that he has some other shady stuff going on (knowing the guy, it wouldn't surprise me).

 

[DOCTORSAIB]

There is an ophtho in the town I grew up in who specializes in cataract surgery. Granted he is probably mid-late career at this point but the guy owns a plane and drives around in a new Maserati. He always seemed a bit out of touch in a small midwestern town populated by middle class blue collar families like mine. I always assumed his wealth was from with ophtho practice but now I'm suspicious that he has some other shady stuff going on (knowing the guy, it wouldn't surprise me).

Ophthalmologists used to make a killing -- back when reimbursement for cataract surgery was ~$2000 an eye. Plus he may have investments elsewhere. Not everyone relies on ONE source of income. So don't go calling the FBI on him yet just yet..

What floors me about ophtho is that it's such a competitive field. You constantly bust your ass in med school (Step 1, AOA, research, etc, etc) to hopefully get a spot. And yet what do you have to look forward to when you're done -- a crappy job market with starting salaries below $100K. That's just ridiculous.

Every competitive field in medicine (Rads, Anesthesia, Derm, etc) at least allows you to reap the rewards of your hardwork with solid salaries and good lifestyles once you're done with residency.

I guess the name of the game in ophtho is fellowship and location. Subspecialize then move to the midwest or down south (Texas is on my radar)...

 

[CuriousKat]

Ophthalmologists used to make a killing -- back when reimbursement for cataract surgery was ~$2000 an eye. Plus he may have investments elsewhere. Not everyone relies on ONE source of income. So don't go calling the FBI on him yet just yet..

What floors me about ophtho is that it's such a competitive field. You constantly bust your ass in med school (Step 1, AOA, research, etc, etc) to hopefully get a spot. And yet what do you have to look forward to when you're done -- a crappy job market with starting salaries below $100K. That's just ridiculous.

Every competitive field in medicine (Rads, Anesthesia, Derm, etc) at least allows you to reap the rewards of your hardwork with solid salaries and good lifestyles once you're done with residency.

I guess the name of the game in ophtho is fellowship and location. Subspecialize then move to the midwest or down south (Texas is on my radar)...

Sounds like a plan. Work your butt off for 4-5 years and then set up shop in Waco. Sweet...

Anyway, sorry to derail the thread. I was just curious. The grass always seems greener on the other side.

 

[ophtho1122]

I am glad there are people here speaking out. I have been in private practice with a group fo the past year. Empty promises, and lies. After busting my ass for the past year chasing the dangling carrot called a bonus, they have decided they can't afford my salary anymore. Nice, right before I would be getting my bonus. I hear these stories all the time. Very few young Ophthalmologists stay with their first or even second jobs. Is it every specialty, or is our specialty particularly predatory? I love my work, but I am starting to become bitter about the reality of private practice for a young doc with no money, who doesn't wish to move to North Dakota.

 

[Shake_yabooties]

as a med student who's working towards ophtho... this kind of thread sort of scares me..

 

[Eyefixer]

Wow, I did not anticipate such a lively discussion on our usually dead forum .

I love what I do, but it's really heard ignoring how a close friend is getting 5 offers from So Cal practices and he is not even in his final year of GI fellowship. One practice is actually offering to pay him $50K per year over the remainder of his fellowship if he signs a contract now. I especially like how "he might decide to end up in a mid-western state away from his family is So Cal and start at $700K his first year".

I don't think any sub-specialty is immune from this, even retina. Keep in mind that even though starting a general ophthalmology/anterior segment practice on your own is as painful as OrbitsurgMD described, but it's much worse for retina. Your start up is much higher, you are on call all the time, etc., so retina specialists almost invariably have to join an existing practice or work in academics. And, if you are lucky enough to join that coveted retina practice in a desirable location, you WILL learn the true definition of predatory senior generation; make no mistake about it. In addition, with perpetual Medicare cuts, do you guys really think retina will continue collecting $$$$ for Lucentis injections?

I do think it is going to get worse before it gets better for us. But once the baby boomer generation is "up and running" with retirement the demand for our services will skyrocket. I just hope we are not all making $40/year under socialized system when that happens.

Thoughts?

 

[DOCTORSAIB]

Sounds like a plan. Work your butt off for 4-5 years and then set up shop in Waco. Sweet...

Anyway, sorry to derail the thread. I was just curious. The grass always seems greener on the other side.

Oh come on man (woman?), Texas can't be THAT bad?

Plus I'm talking about places like Houston, Austin, etc. It's a great state overall for a doc to start practicing and for so many reasons. Look into it..

 

[CuriousKat]

Oh come on man (woman?), Texas can't be THAT bad?

Plus I'm talking about places like Houston, Austin, etc. It's a great state overall for a doc to start practicing and for so many reasons. Look into it..

I have actually. Admittedly, I only know about the gas and rads market and this is only from talking to friends who are currently on the job market. Austin is highly desirable (with starting salaries 50-75% of what they would be in northern Michigan, etc.). Houston may be slightly less desirable but there are alot of residency programs in the area pumping out grads. I doubt the situation is any better for ophtho there (may be worse judging from the comments of ophtho1122)

Seriously, think about Waco. I am!

 

[eyehope]

Not sure if this is ophtho specific, but statistics show that 80% of docs will move at least once in their careers. But, it isn't so easy to pick up and leave. My family loves the area. It's tough to start "all over again," leaving a practice that you have slowly built up.

For those interested in the field, it is difficult to predict future salaries. But, IMO, I do not see starting salaries changing much in the next five years (beyond normal inflation). Perhaps this will change as the baby boomers age, increasing demands for our services.

Yes, it is not unheard of to start below 100k in desirable cities such as Chicago, NYC. Look at the AAO job website. Offers are in the low 100s (below 130k) in most areas. If you are lucky enough to start anywhere close to 200, you will find yourself in upper Michigan, far upstate New York, or Wisconsin. Again, I just do not understand it. Adding another doc should not increase overhead much. If a practice is really in need of another doc, even the most lazy new doc can support his/her salary over the first year.

I am glad more people are speaking out, but can someone provide a glimmer of hope?

 

[ophtho1122]

Houston is saturated. There is an Ophthalmologist on every corner, even going as far as 30 miles out of the city. With 3residency programs pumping out docs into the community, and a huge optom school doing the same, it would be really difficult to start your own practice here unless you can afford to live off of peanuts for several years. Average young doc here in general make $150-185k for at least the first 2-3years in practice. Not the $250k+ I had hoped for after several years in practice. LASIK is dead and multifocals aren't driving revenue as much as LASIK did. The "good ole days" are over, for now anyway. Not quite what I dreamed about when I was busting my hump through medical school and residency to get into this field.

 

[Just Applied]

.

 

[KHE]

I appreciate your input. I like to keep this discussion going; I am just curious what other people think out there.

Without going into too much detail, I have spent about 6 months working per diem in a few places in a very competitive area. I thought about solo, associate, etc. positions. I did start early in residency and was able to get everything squared away by July 1st of my senior year (license, dea, most insurance panels, medicaid, etc.,etc.). I understand that the economy plays a huge part in this and that I probably graduated during the worst possible time (well, residents graduating this year are doing so during the worst possible time ), and here is what I have observed: I witnessed refractive volume drop about 80% in just a few months (evidenced by the volume numbers in the refrective ASC where I had priviliges). That led a lot of local guys who were >50% refractive for the past 15 years pick up more general stuff, lay off some staff, shorten working weeks, etc. That in turn is hurting everyone else. I know a few guys retirement age taking extra clinic days and a few closing up shop. Can a young guy consider buying a practice being closed? Sure, but what are you buying? There is a trend nowdays where practices are way overvalued and everyone knows that including the buyers. How does one calsulate "good will" nowdays?

Moreover, a lot of guys I have spoken with won't even give you a salary. "Well, you come in and I'll just give you precentage of your collections and then we'll see...". B*****t, that's no way to start someone out even though this is the easiest for the practice owner.

All in all, I agree with you. It's amazing how our services are undervalued. Cataract surgery pays around $650 now. According to chats on ASCRS and other forums, $500 is a break point for most people. If it gets less than that, people would stop operating because they can make more money in clinics. And ophthalmology services is projected to have the highest demand jump by 2020 only second to cardiology services.

What I have seen in the last 6 months made me very unsure about private practices nowdays. Don't get me wrong, I think you can still do pretty well if you are willing to skip New York, LA, SF, etc. But if you are not willing to do that, you will find job market tougher than you expect.

Having said all that, Kaiser is starting to look better and better. Even with all the negatives you've listed.

I'm starting to work with my second ophthalmologist getting him set up in private practice. He reported a similar scenario to what others on here have posted which is why he's going out on his own. I would like to pose some questions to this forum:

1) What percentages are you normally being offered with respect to your collections? 20,30,40,50% of collected?

2) For those offered a flat salary and/or bonus structures, what are the general nature of these? In other words, if you are offered $150000 as a salary, how much in billings are you expected to generate for that?

3) Where do your patients come from? Are you mostly taking on overflow from other practitioners or are you expected to pound the pavement to bring new patients to the practice?

I would not shy away from starting or buying your own practice. Truth be told, the last young ophthalmologist that I helped get started is in his 3rd year and is on pace to make $230k this year after making $195 last year after a cold start up. This is in Connecticut, not exactly known as the land of cheap anything.

 

[superretinadoc]

Eyefixer-

Which Kaiser ophthalmology are you thinking of joining? I know several people who are at the Ohio region Kaiser who are miserable there. They really overwork their doctors in that region and from what I know none of the doctors who work there are very happy and are either looking to get out or counting down their days until retirement. In the past 5 years, more than 5 ophthalmologists have left due to being unhappy and overworked. I am in private practice and am loving every minute of it.

 

[orbitsurgMD]

I'm starting to work with my second ophthalmologist getting him set up in private practice. He reported a similar scenario to what others on here have posted which is why he's going out on his own. I would like to pose some questions to this forum:

1) What percentages are you normally being offered with respect to your collections? 20,30,40,50% of collected?

It varies, but a typical share is 30-45% of collections above some threshold, usually a multiple of the base pay, 2-2.5X, typically (but not including benefits, malpractice or continuing educational expense).

2) For those offered a flat salary and/or bonus structures, what are the general nature of these? In other words, if you are offered $150000 as a salary, how much in billings are you expected to generate for that.

Again, it varies. If you aren't assuming another doctor's practice (departure, retirement, etc.,) it will take many months to generate enough collections to cover both salary paid and all net new costs reasonably attachable to the new doctor--licensing, additional support staff, advertising, hospital fees, new equipment, malpractice insurance, clerical costs, stationery and additional billing and collections costs. (Not the same as the nominal "overhead" charged, 50%, 60% etc.). Most practices will hope to see a new hire free and clear of his net expenses before one year.

3) Where do your patients come from? Are you mostly taking on overflow from other practitioners or are you expected to pound the pavement to bring new patients to the practice?

Depends on the skill set. Sub-specialty trained people will get a mix of overflow, internal referral and are usually expected to make an effort to secure external referrals as well.

I would not shy away from starting or buying your own practice. Truth be told, the last young ophthalmologist that I helped get started is in his 3rd year and is on pace to make $230k this year after making $195 last year after a cold start up. This is in Connecticut, not exactly known as the land of cheap anything.

Buying . . . depends. Most sellers tend to wildly overvalue their practices, commonly with the support of estimates provided by practice valuation "experts" who are paid by the practice owners and who tend to stroke the egos of their clients by providing inflated valuations. There is no penalty to a valuation consultant for over-valuing a practice that subsequently doesn't sell (by contrast, under-valuation leaves clients feeling they were poorly-served.) These estimates of value are commonly based on historical models which in ophthalmology result in skew toward over-valuation, given downward trends in per-procedure payment, offset mostly by volume which ultimately becomes finite.

 

[KHE]

Ok,

When people on here talk about getting "screwed" or "preyed upon" by older practitioners, what does that exactly mean, and do you think it's intentional?

In other words, do people feel that they are being underpaid? Are terms of contracts baited and switched? Are there offers of partnership that never meterialize, and if so why?

In my field, I dealt with this type of thing a lot. The common way of doing things in optometry (or so I was told) was that a young doctor coming out of school partners up with some old guy and after a couple of years, the young guy increases his time and ownership while the old guy slowly fades away.

In practical terms, this never really worked out this way and this is why, at least in optometry.

Often times what happens is when some young blood comes on board and starts building or adding to a practice, the owner doctors then start to make some serious money off of the back of the young doctor. In theory, I don't have a problem with that because in theory, I've been paid a living wage for my work. But the problem becomes that as the older doctor starts making more serious money, the incentive to deal the younger doctor in becomes less and less. Partnership, or ownership gets pushed off further and further into the future while the seniordoc keeps claiming "I'm not ready yet" which usually means that the WIFE isn't ready yet. The frustrated young doctor then leaves to repeat the process elsewhere.

I dealt with this a LOT before buying the practice I did. I'm very happy now and make great money but that process is repeated over and over in my field. The thing is though, I don't think it's intentional on the part of the seniordocs. I don't think that they are sitting there maniacally rubbing their hands together conjuring up ways to screw young doctors. It just sort of happens.

In your cases, what exactly is the problem and do you think it's intentional?

 

[ophtho1122]

In my case, this guys has pulled the same crap in the past. Yes, I did ask around before I joined. What I find, is because Ophthalmology is such a small community, people tend to keep their mouth shut, and really do not want to talk bad about another older doc. Now that I am leaving, everyone is speaking up. Too bad they didn't speak up a year ago!

 

[KHE]

In my case, this guys has pulled the same crap in the past. Yes, I did ask around before I joined. What I find, is because Ophthalmology is such a small community, people tend to keep their mouth shut, and really do not want to talk bad about another older doc. Now that I am leaving, everyone is speaking up. Too bad they didn't speak up a year ago!

Ok, so in your case you feel that the practice partners made a conscious decision to terminate you right before the bonus was to be paid out simply so they would not have to pay the bonus and you feel that this was the plan of the practice all along? Wow. That is quite ****ty.

I think a good provision for new graduates taking on these positions would be to have a clause in the contract that any bonus money will be pro rated up to their last day of work in the even of departure.

 

[ophtho1122]

No, actually what I think their plans were is to string me along on my salary for a couple years, while growing their practice base, and run me off by putting off partnership etc.,....bring a new guy on and do the same while all along building up the practice and having the practice O.D.'s assume those patients once I am gone, sending the surgeries back to the senior docs. I was going to hit bonus way before any of the previous associates, and with the economy hitting their overall business, it was better to cut ties now. Probably better for me in the long run, but in the short term, really sucks!

 

[KHE]

No, actually what I think their plans were is to string me along on my salary for a couple years, while growing their practice base, and run me off by putting off partnership etc.,....bring a new guy on and do the same while all along building up the practice and having the practice O.D.'s assume those patients once I am gone, sending the surgeries back to the senior docs. I was going to hit bonus way before any of the previous associates, and with the economy hitting their overall business, it was better to cut ties now. Probably better for me in the long run, but in the short term, really sucks!

So again, you believe that that was the plan before they even hired you, or was it just that that was how it worked out?

If you thought it was their plan right from the start, was there a reason you took the position in the first place? Not trying to be nosy, but I'm getting into a bit more consulting and it's helpful to be able to draw on other people's experience.

On some level it's also good to know that it isn't just something that happens in optometry.

 

[orbitsurgMD]

So again, you believe that that was the plan before they even hired you, or was it just that that was how it worked out?

If you thought it was their plan right from the start, was there a reason you took the position in the first place? Not trying to be nosy, but I'm getting into a bit more consulting and it's helpful to be able to draw on other people's experience.

On some level it's also good to know that it isn't just something that happens in optometry.

That is a common story.

Hire a new guy. Everyone in the practice takes less call, and less holiday call. The net cost is generally manageable: startup salary, malpractice, maybe a new tech (but usually not, just a shifting of responsibilities), perhaps a small capital equipment investment (but again, often not), and hospital application and society membership fees. Usually the new associate has met his net added cost--i.e. "covered" himself before the end of the first year, sometimes well before then. Once done, all that is necessary is to get him to do some more work, and the earnings go straight to the partners. Keep him interested with a little taste of a production bonus, maybe even promises of a buy-in plan, perhaps promise a share of a surgery center, and pretty soon, he has developed a full, busy and profitable practice.

Then you screw him. Do things to him and his practice that would make anyone unhappy. Renege on the partnership deal. Cancel his contract.

Now you go and hire a new associate. Only this time, you don't have to wait for him to build up a practice; his predecessor did that for him. He becomes profitable right away. And guess what, he is motivated by promises of a bonus and partnership just like the first "associate" was. Good deal.

Serial hiring can be very profitable. And you know, those expressions of pained regret when someone interviewing asks about the guy who left: "Oh, he just never seemed happy." "We tried to help him, but it just didn't work out." "He wanted to live somewhere else in the country." (Good thing if he had a non-compete locking him out.)

There are plenty of these kinds of guys around the country. Their practices are always advertising for new people on the AAO Professional Choices webpage, and in the throwaway journals. Yes, local docs are often reluctant to say what they think of other doctors, even ones that really have bad reputations. They want to avoid trouble.

Here is a hint: if they don't say great things about that doctor, if there is even the slightest hesitation, take that as a bad sign.

And call the former associate doctors. Try to track them down and get them to talk with you. That is probably the most helpful thing to do. Be persistent but polite. Keep what you hear in confidence; you are trying to make a personal decision, for yourself, not others. If there is reluctance to endorse the practice, that is a sign the practice was not a good opportunity. If they say they have agreed not to discuss the practice as a condition of some settlement, you can draw the obvious conclusions.

Call some of the local optometrists, too. They are usually more ready and able to say what they think.

There are a lot of predatory older docs that do crappy things to new hires and have all sorts of sociopathic rationalizations for why things don't work out. It is really a shame more of them aren't outed for what they are and what they do.

 

[Eyefixer]

Fantastic post. Add to that a miserably small number of practices hiring in LA, NY, etc. and legions of newly graduating residents and fellows every year... You get the picture.

That is a common story.

Hire a new guy. Everyone in the practice takes less call, and less holiday call. The net cost is generally manageable: startup salary, malpractice, maybe a new tech (but usually not, just a shifting of responsibilities), perhaps a small capital equipment investment (but again, often not), and hospital application and society membership fees. Usually the new associate has met his net added cost--i.e. "covered" himself before the end of the first year, sometimes well before then. Once done, all that is necessary is to get him to do some more work, and the earnings go straight to the partners. Keep him interested with a little taste of a production bonus, maybe even promises of a buy-in plan, perhaps promise a share of a surgery center, and pretty soon, he has developed a full, busy and profitable practice.

Then you screw him. Do things to him and his practice that would make anyone unhappy. Renege on the partnership deal. Cancel his contract.

Now you go and hire a new associate. Only this time, you don't have to wait for him to build up a practice; his predecessor did that for him. He becomes profitable right away. And guess what, he is motivated by promises of a bonus and partnership just like the first "associate" was. Good deal.

Serial hiring can be very profitable. And you know, those expressions of pained regret when someone interviewing asks about the guy who left.
"Oh, he just never seemed happy." "We tried to help him, but it just didn't work out." "He wanted to live somewhere else in the country." (Good thing if he had a non-compete locking him out.)

There are plenty of these kinds of guys around the country. Their practices are always advertising for new people on the AAO Professional Choices webpage, and in the throwaway journals. Yes, local docs are often reluctant to say what they think of other doctors, even ones that really have bad reputations. They want to avoid trouble.

Here is a hint: if they don't say great things about that doctor, if there is even the slightest hesitation, take that as a bad sign.

And call the former associate doctors. Try to track them down and get them to talk with you. That is probably the most helpful thing to do. Be persistent but polite. Keep what you hear in confidence; you are trying to make a personal decision, for yourself, not others. If there is reluctance to endorse the practice, that is a sign the practice was not a good opportunity. If they say they have agreed not to discuss the practice as a condition of some settlement, you can draw the obvious conclusions.

There are a lot of predatory older docs that do crappy things to new hires and have all sorts of sociopathic rationalizations for why things don't work out. It is really a shame more of them aren't outed for what they are and what they do.

 

[Just Applied]

.

 

[nsxracingy2k]

Thank you all for sharing your valuable experiences. I probably won't change my decision to pursue ophtho, but at least now I am aware of what might hold in the future for me.

 

[EyeMD116]

Hey everyone, thank you for posting your experiences. Like a few other posters on here, I am a medical student with a deep interest in ophtho. This thread is certainly concerning, but I hope that there is another side of the coin we haven't heard yet. I feel that if Ophthalmologists made killer salaries in the 300K+ range, along with all the other perks (lifestyle, etc.) this would be too perfect a specialty.

How do you guys think specialization helps job prospects? I know Retina docs do well, but how would Glaucoma/Cornea guys-- does it make it easier to find a position in a private practice?

Also, how are average ophtho salaries in the low-mid 200's if people are starting so low? (150K for example).. who are the people making over 250K? I would think Academic docs make less, so the private practice guys would do even better than the mid 200's average..

 

[WhatNEyeTem]

Hey everyone, thank you for posting your experiences. Like a few other posters on here, I am a medical student with a deep interest in ophtho. This thread is certainly concerning, but I hope that there is another side of the coin we haven't heard yet. I feel that if Ophthalmologists made killer salaries in the 300K+ range, along with all the other perks (lifestyle, etc.) this would be too perfect a specialty.

How do you guys think specialization helps job prospects? I know Retina docs do well, but how would Glaucoma/Cornea guys-- does it make it easier to find a position in a private practice?

Also, how are average ophtho salaries in the low-mid 200's if people are starting so low? (150K for example).. who are the people making over 250K? I would think Academic docs make less, so the private practice guys would do even better than the mid 200's average..

Average means just that. A private practice person in his/her mid 40's is going to have a higher surgical/patient volume than someone just finishing residency/fellowship.

150K is a realistic starting base salary for most new Ophthalmologists...especially if they are practicing in a desirable area (eg. California).

-J

 

[MDEYES]

nevermind

 

[happy optho]

Hello ,

I was reading this thread the other day and it scared the H out of me, I was looking at job postings on the AAO website and the average starting salary was 130`s in most cases and 150`s for retina.

But my question is; will this remain the trend or will you be making more as the years progress and you build up your patient base.

also when they offer these wages how many patients do they expect you to see initially, bec if I am being paid 130 K to see half of what the already established physician is seeing then I will not be so scared,

P.S. I am starting ophtho residency next year and I will never change the field cause I just love it and I will never change it or have financial issues change my mind.

 

[Transition Consultants]

Buying . . . depends. Most sellers tend to wildly overvalue their practices, commonly with the support of estimates provided by practice valuation "experts" who are paid by the practice owners and who tend to stroke the egos of their clients by providing inflated valuations. There is no penalty to a valuation consultant for over-valuing a practice that subsequently doesn't sell (by contrast, under-valuation leaves clients feeling they were poorly-served.) These estimates of value are commonly based on historical models which in ophthalmology result in skew toward over-valuation, given downward trends in per-procedure payment, offset mostly by volume which ultimately becomes finite.

Good point. That's why an appraiser worth their salt will temper their valuation with a market approach. All the good appraisal logic is subject to the realities of the market. Most importantly, the appraisal must take into the account the most recent performance of the practice. A 5 year historical perspective will say very little about the true performance of the practice if the last 6 months look like dog meat. Plus it is very challenging to get a deal financed if the practice is in decline.

 

[Mirror Form]

If you thought it was their plan right from the start, was there a reason you took the position in the first place?

As opposed to what? There aren't many available jobs out there in most cities. Even the mid-sized cities now are getting extremely over saturated with ophthalmologists.

 

[Mirror Form]

sorry no one has replied yet. i work in private practice so this is not insider information.

pros
1. built-in referral network
2. higher starting salary
3. better health/pension/retirement benefits
4. do not have to worry about billing/insurance (but probably true for most large groups)
5. less busy clinic schedule

cons
1. lower potential income
2. larger organization - dealing with the bureaucracy (esp with hiring/firing of techs)
3. perhaps less flexibility with vacation scheduling (?)
4. no ownership of the practice

I'd disagree with your assertion that Kaiser has a less busy clinic schedule. I know some ophthalmologists who work for Kaiser and they are extremely busy.

 

[WhatNEyeTem]

Hello ,

... I will never change the field cause I just love it and I will never change it or have financial issues change my mind.

(Medical student) Ignorance is bliss...


Just wait until you have to support 3 kids through college....