Tag: private practice

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Should I Join A Practice With A High Buy-in?

buy-in

As of the end of 2020, the job market is beginning to improve post-covid. And, for those of you considering your first job nowadays, you may receive offers from multiple practices. And, some of those offers may seem enticing. Perhaps, you hear that the partners make 600,00o, 700,000, or 800,000 dollars or more. And when you interview, the President of the private practice tells you that you will have to pay a large sum of money into the business. This sum of cash called a buy-in can range from zero to as high as into the millions. So, here are the questions you need to answer. Is a high buy-in ever worth your while? In fact, should you even entertain the possibility of starting at one of these practices that come with an enormous buy-in? Well, I am here to help you to answer these questions today!

 

 

The Hope

OK, all things considered, paying into a practice a large sum of money doesn’t sound so bad if the practice guarantees that you will bring in gobs of money each year, right? If you are paying a million to own a radiology practice’s technical shares, you can potentially receive outsized benefits in return. For one, your salary can become much higher. That initial sum of money that you add to the practice equity can significantly increase in value if the practice does well. You can also diversify your income a bit by collecting the professional fees and the technical component. These hopes can all come true.

But Then…

OK. There is always more to the story. Practices can dash hopes in an instant. Let’s say you don’t receive a share of the partnership during your partnership track. Where does that leave you? A lot poorer!

Or, perhaps, the practice equity declines as you finally earn the golden ring of partnership. Can a practice’s equity decline that much? Sure, can! Assets can not only decline to zero but can become a debt burden as well. Think about it. Equipment depreciates. And physical properties can decrease in value. The money you put in can no longer exist after you put all that equity into the business. And some!

Besides, you may overpay for the practice more than it’s worth. Who is to say that you have paid a fair price to become a partner? The practice partners? How do you know if they know how to value the practice. Or, maybe, they are trying to defraud you. You never know.

Weighing The Risks Versus Benefits Of A Large Buy-in

So, let’s see. The potential for large rewards versus the possibility of paying into something that is not worth it. What should you do? As always, this comes back to a trust and numbers game. Only by vetting the practice’s balance sheet and getting detailed information about the practice owners can you make the decision. So, how do you go about making this weighty decision?

Of course, you need to assess the people that run the practice. But how? Track record becomes very important. Have they strung along with multiple employees on partnership track to never make them a partner in the business? Are these physicians respected members of the radiology community? Do your residency and fellowship directors know something about the practice?

To get at the matter of trust, you must research the practice well. Check for lawsuits and hiring indiscretions. These can all become red flags that the imaging business may not be what you think.

And then get to the bottom of the balance sheet. Be wary of any practice that does not let you know what the partners have made in the past. Think twice if the practice does not allow you to talk to the business manager about the finances and the assets the practice owns. I know of several radiologists who had been through an extended partnership track to find out that they became partners in only the professional component, not the technical component/equipment and real estate. They were sorely disappointed when the time came to make “partner.” So, make sure to find out what you are really “buying-into”!

Finally, you need to consider the current environment of the practice. Are private equity firms or large hospitals in the area taking control of practices? Is the area economically growing or contracting? These factors may influence the risk of entering a partnership track that you may not be able to complete.

A High Buy-in And Your Final Decision

Depending on the situation and the practice, a high buy-in may or may not be worth the risk. Take into account not just the great potential of the business. Instead, you also need to consider the risks you need to take to earn that potential outcome. It might turn out well, but it might not. So, maximize your probabilities of success. Do your due diligence!

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Should I Continue With My Fellowship After Years In Private Practice?

years in private practice

Question About Fellowship After Years In Private Practice:

I am an experienced radiologist and decided to join a fellowship after 12 years in private practice. Some people thought I was mad, and some thought I was going through a midlife crisis. I was sick of private practice work and wanted to do something new as I felt I was getting deskilled. So, I joined a fellowship in a tertiary hospital. Two weeks into the fellowship, I think I have become a bit slower and a little out of depth. I expected this change, and I thought it would take a few weeks for me to get up to speed. But now I feel I am very unwelcome because I am an outsider and there is a lot of politics.

I don’t know why I am writing to you, but I thought you might have seen a case like me and could provide some insight into my situation.

A Political Outsider

Response:

Dear Political Outsider,

I admire your tenacity to go back to fellowship. Sacrificing your current life for educating yourself after years in private practice to do something more speaks volumes about your determination and work ethic. Our most incredible residents are ones that have had prior experience. We have had one or two who completed former residencies in their own country before coming to our program.

Unfortunately, it sounds like you have entered a fellowship where education may sometimes take second priority to the whims of the folks who run the program. You have to decide if it is worth it to overlook the politics of your situation to receive the education that you wanted to get initially, Or do the politics of the place prevent you from accomplishing the goals that you had intended to get from the fellowship in the first place? It is often worthwhile to tough it out to get your education. A fellowship is for a relatively short period compared to years in private practice. So, if you can take the pain, it may be worth it. Especially if the tools you are learning will be essential to your future radiology practice.

Regards,

Barry Julius, MD

Question:

Hi Barry

Thank you so much for your feedback. Currently, I am doing the fellowship on my academic drive. It would have been nice if the department’s environment would have been additive.

I had joined the fellowship to gain more training. It appears all scans are done by consultants on weekends as they get paid extra by the department. So they have a vested interest in not letting us fellows report them.

The other day, I was in a meeting, and two radiology consultants mauled me in front of 30 doctors. They kept unsettling me while I was presenting and tried to humiliate me. I still have no clue what was their vested interest.

I want to thank you again for your encouragement.

Regards,

A Political Outsider

Response:

Dear Political Outsider,

Usually, those attendings/radiologists who exhibit bad behavior during a meeting do not reflect your competency. Instead, it measures the insecurity or mean-spiritedness of those who commit the inappropriate behavior. If these radiologists had an issue with you during the meeting, they should have taken you aside and spoken to you privately. Unfortunately, sometimes, in fellowship, you must keep a thick skin and try not to let these episodes derail your excellent work.

Good luck,

Barry Julius, MD

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Radiology Swap- University Radiologist Goes To Private Practice (Part 2)

radiology swap

Today we return to Part 2 of our Radiology Swap blog. Click on Radiology Swap- Radiology Private Practitioner Goes To University (Part 1) to catch up if you missed the first part of Radiology Swap!

University Radiologist Goes To Private Practice

Day 1 Radiology Swap:

Unaccustomed to working in a private office, the University radiologist is surprised by the relatively small size of the office. The parking lot is not too full, and he can walk rapidly from his car to the office, very different from usually having to walk from the back of the parking lot—a nice perk.

Finally, entering the building, he locates his workstation and seat. As soon as he sits down at the desk with the PACS monitor, a technologist dumps a stack of papers with today’s work next to the monitors. It must be about 150 cases. Where are my resident and fellow? I need them to help me with the dictations! Oh, my God!!!! I just realized that I forgot how to use a dictaphone.

After struggling with dictations and having read maybe 10 of them, 11 AM rolls by as he teaches the technologists about the ultrasounds they show him. But, the technologists roll their eyes as they just want to get through the cases so they can go home. They sense him droning on and on! He looks at the stack of papers given in the morning. It still looks the same!

Noon: He begins to receive phone calls, not happy ones. Clinicians are asking him about the results of chest x-rays, ultrasounds, and MRIs. Unsuccessfully, he tries to soothe them and let them know he has not looked at them yet, but he will get to them! No lunch for me.

Eyes reddened, head bleary, and voice cracking, the University radiologist now realizes it is almost 5 PM. He has only finished maybe half of the stack of orders. Lots more to go. No one to talk to. I can’t leave yet to get to the family.

10 PM arrives, and he is finally finishing his last dictation of the “day.” How does the private practice radiologist do it?

Day 15 Radiology Swap:

He arrives wearily into the office, looking haggard and worn with a 15 lbs weight loss since he started the job (1 pound per day!). His temper flares every once in a while, taking out his frustrations on the constant bombardment by the technologists by making snide remarks and yelling at the staff’s mistakes. For the past 15 days, he has left the office in the dark, no earlier than 8 PM. No direct contact with interested learners or other clinical physicians. All interactions on the phone. So, this is physician burnout!

Day 30 Radiology Swap:

Assessment day for Radiology Swap!!!

Practice President: So, you have worked in our practice for the past 30 days? Let’s start with the good part: I’m glad to see that you have made it through the encounter.

Academic Radiologist: Yeah, barely. How do you guys do it?

President: We do it efficiently to make money. The more we read, the more we earn. It keeps us going. In any case, let’s continue with your review. We received many complaints from our staff that you were curt and inappropriate at times. It was like pulling teeth to get you to do fluoro cases on our patients. You kept on grumbling- “Where’s my resident?”

Academic Radiologist: I thought you would at least provide me with a physician assistant to help with daily work. I don’t usually touch patients. My residents do it for me.

President: We also received numerous complaints from our referrers that they did not receive their reports in a timely fashion. We lost some serious business this week.

Academic Radiologist: When you get 150 new studies per day, everyone has to wait!!!

President: I don’t think we would be able to keep you here because we need radiologists to keep up with the work. We don’t get paid if we don’t read the minimum volumes!

Academic Radiologist: The best part of this job was the 15 lbs weight loss! I can finally get some sleep again. His eyes begin to close, dreaming about returning to his academic position.

 

The Radiology Swap Meetup

So, the academic and private practice radiologists now seat themselves in the same room to share their experiences after having returned to their respective jobs.

Private Radiologist: How do you do your job on a daily basis without getting totally bored?

Academic Radiologist: How do you do your job without getting totally burnt out?

Private Radiologist: Let’s agree that we are not right for each other’s jobs. It would never work out for us.

Academic Radiologist: At least I can understand what you go through on a daily basis. We used to make fun of private practice radiologists. Don’t think that I will do that anymore.

Private Radiologist: Doesn’t mean that we can’t be friends. Let’s go out for drinks! I think we both earned it…

Academic: True. We both earned some stiff ones.

The radiologists leave the room and head down the street, never to look back on their former residency swap experiences again and happy to go out for some drinks…

THE END

(until next time!)

 

 

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Radiology Swap- Radiology Private Practitioner Goes To University (Part 1)

swap

Ever watched the show called Wife Swap? Essentially, women of two households “swap” roles and responsibilities for different families and share their experiences with the TV audience. It’s a lot of fun to watch! Like this exercise, I thought it would be fun to speculate on what would happen if you swapped a private practice and academic radiologist for a month. How would each experience the other’s world? What would be the trials and tribulations? Let’s see!!!

Radiology Swap- Private Practitioner Goes To University

Radiology Swap Day 1:

The private practice radiologist walks into his university radiology reading room for the first time. Looking around, he encounters a group of 2 medical students, one resident, and one fellow waiting for him to read out the films from yesterday evening and the morning. He thinks: Why are all these people here? Do I need four additional trainees to look at the ten cases left over? This excess is sort of ridiculous!!!

He begins to sort through the pre-dictations of the radiology resident and fellow. As the cadre of 4 trainees looks over his shoulder, he looks at the first dictation and decides to erase everything. Although he feels a little bit self-conscious from all the stares over his shoulder, he starts all over from scratch. He doesn’t like the way the resident words the dictation. It’s too freakin’ long. Rapidly, he runs through each resident and fellow’s cases, erases each, and re-dictates everything.

Only a few additional cases come through the department, and the resident/fellow handles each before looking at the images. They are tertiary referrals from another facility and are very complex, but he does not perseverate and completes the cases in 30 minutes. Staring at the clock, he begins to walk around. Well, not much going on. I’m going to grab some breakfast!!!

After grabbing breakfast for 15 minutes, he arrives back at the reading room. Two more cases show up. The residents, fellow, and student seem to wait for the radiologist expectantly. Again, he promptly erases the resident and fellow dictations and quietly reads the two cases very slowly with the team, trying to pass the time. This day is Chinese water torture! Learning to run intermittently once every few hours from his office to the reading room, the day continues, as is, until work ends at 5 PM.

Radiology Swap Day 15:

It’s the weekly admin slot. On the schedule today, the radiologist attends a tumor board with bleary eyes at 7:00 AM. Not accustomed to the so much time spent on each case, it is hard for him to stay awake. But he manages. Next, at 8 AM, he attends a meeting to discuss performance reviews for the technologist staff. For half of the conference, the attendees discuss when the next meeting will occur. Ugh!!! What a waste of time! 

He quickly dots off to read a few films to help out his colleagues instead of perching himself at his desk to write a grant. He has writer’s block. What the hell should I be writing now? I haven’t written anything but a dictation for 20 years!!! He sits and sits and finally falls asleep at his desk.

Noon arrives. Thank God it’s lunchtime. Something to do!!! He happily runs down to the cafeteria to eat. He stretches out his lunchtime meal for one hour when the next meeting starts. Quality improvement initiative is the theme of the next conference. Could they think of a more boring topic to meet about?

It’s now 3 PM. He begins to meet with the backup staff in the department to discuss increasing resident and attending research output. This group includes the research coordinator, the head of research, the research financier, and the student research liaison. A recurrent thought flashes through his mind during the entire meeting. Who pays for all these extraneous people and why? I would cut the fat here immediately if I could!!!

Radiology Swap Day 30:

Assessment day! The department chairman sits the private practitioner down to summarize the events that ensued over the past month. The conversation goes something like this:

Chairman: I am impressed that you got all the work done quickly. They can be challenging cases. Our other academic radiologist never seems to get to read all the films.

Private Radiologist: Really? He only read 20 films per day!

Chairman: However, you did not apply for one grant; you did not even start on one paper. And, the physicist caught you sleeping at several meetings. Publish or perish!

Private Radiologist: Well, it’s challenging to write anything when you haven’t written a paper for over 20 years! How do you not sleep when half your meetings are about when the next meeting will be?

Chairman: And, your student, residents, and fellow claim that you rewrite all their dictations. You then grumble how they don’t know how to dictate and forget that they are there. Teaching is an integral part of academic radiology.

Private Radiologist: I don’t understand why they have to be there. They don’t do anything but stare over my shoulder!

Chairman: Although you can make it through all the films, your academic prowess is very poor. Academic radiology is not for you.

Private Radiologist: Thank God I can return to my private practice tomorrow!

See you next week for part 2!!!

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Is The New DR-NM Pathway Worthwhile?

DR-NM pathway

Message For The Director
Hi,
Can you kindly comment on the ABR/ABNM 16-month dual pathway? Is it worth it? Can one get a job without another extra year of fellowship?

Interested Resident

 

 

 

 

 

I would love to talk about the DR-NM pathway. I am an ABR and ABNM certified radiologist, so I am interested in this matter.

Reasons To Not Participate In DR-NM Pathway

If you are going into the DR-NM pathway, you may find a job after the 16-month program during your residency. However, for most people, I would probably opt for the more traditional route for several reasons. First, you will have much less training in general radiology. For most radiologists coming out of residency, you want to maximize your experiences in general radiology so that you feel comfortable in most modalities. You are replacing 12 months of general radiology with almost exclusively nucs. If you have less general radiology, you are less likely to be comfortable with modalities other than nuclear medicine when you work as an attending in general practice. Most radiology residents work for private practices, with some general radiology.

Second, it may be slightly less desirable for most private practice employers to hire someone with less “radiology” experience. Since this DR/NM pathway is so new and there is less general radiology training, employers may recognize this pathway as a second tier.

And finally, you are pigeonholing yourself into nuclear medicine from the beginning. Most programs will want to know that you will complete the DR/NM program as early as possible (perhaps even from day one of residency!) since scheduling mandates that you need a specific set of rotations. Unfortunately, most trainees have no idea what they want to do at the start of residency.

One Reason To Participate In DR-NM Pathway

So, who would be suitable for this program? The individual that has known for a very long time that they want to specifically subspecialize in the nuclear medicine field. Also, this person should be interested in a primarily academic job (I think that would be the one area where employers would find candidates completing this pathway most enticing).

Final Thought

I’m not quite sure where you stand. However, I would generally recommend the standard one-year nuclear medicine fellowship for most trainees.

I hope that helps!

Director1

 

Click here for more information on the DR/NM program.

  

 

 

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Radiology Private Practice Versus Other Career Pathways- Is It Worth “The Extra Money”?

private practice

The herculean question up for debate: is a private practice career path worth the extra money? To answer this question, you have to know your career options. Suppose you are talking about standard career options for the radiologist (not the alternative career paths discussed in a prior post). In that case, you can divide it into three main choices: private practice, academic/government, and the hybrid model.

Lucky for you, if you are reading this article and you are now making this decision, you have come to the right place. I have worked in the world of academics as a fellow and dabbled in private practice at my first job out of training at Princeton Radiology. Now, I work at Saint Barnabas Medical Center, where we operate with a hybrid model (I was also formerly a resident at a program with a hybrid model-Brown University). Since I’ve been through it all, I am uniquely qualified to talk about how to decide between each option. So, I am going to do just that!!! (Don’t let other posers fool you!)

Are There Income Differences?

What is the difference in income for an academic practice radiologist versus a private practice radiologist? If you look at the Medscape Radiologist Compensation Report from 2016 (later surveys did not have this information!), the academic radiologist made around 262,000 dollars (in this category also is included the military and government physician). On the other hand, some of the other private practice type radiologists made significantly higher amounts: the office-based solo practitioner- 434,000 dollars; the office-based single-specialty group practitioner – 386,000 dollars; and the typical hospital compensated radiologist- 381,000 dollars. So, suppose you take these debatably inaccurate academic and private practice numbers into account. In that case, a pretty substantial difference exists between the income of private practice and academic radiologists (almost 100-150 thousand dollars per year).

It’s Not Just About The Income Though!

But not so fast! In terms of numbers alone, the actual compensation may not account for other benefits like pension and health care. Employees that work for the government or large institution academic hospitals can sometimes receive substantial fringe benefits such as a pension of 70-80 percent of the final salary. Or, they can get incredible health care insurance that you cannot earn elsewhere. Finally, some have other perks, such as free tuition for children in college.

Moreover, the typical smaller radiology private practice will not give these perks. If you take the pension alone, that could amount to a guaranteed (0.8)(262000 dollars per year) or about 210,000 dollars for the rest of your life based on 2016 salary numbers. You would need to have 5.24 million dollars in the bank to have that kind of money guaranteed annually, assuming a 4 percent relatively risk-free return. So, the difference may not be as substantial as initially thought at first glance.

So, now that I have debunked some of the income-based differences (there are always exceptions to every rule!), let’s talk about the different models and decide which option is the right one for you. Let’s start!

The Academic/Government Model

In the purely academic or government model, the primary goal is not reading films and making money. Instead, you will need to publish, teach, or exist (if you are talking about a place like the VA hospital!). Prestige and promotion results from these activities. For comparison, the typical private practitioner couldn’t give a lick about these job requirements. The philosophy is often: publish or perish!

The typical academic sort writes a lot, obtains grants, and is responsible for his/her residents’ teaching and welfare. He/she typically reads fewer studies and sees fewer patients than a typical private practice radiologist. But, that may vary depending upon the institution for which you work. He/she gives many conferences, travels all over the country/world to give lectures, mingles with other academic sorts on all different types of committees, and plays a significant role in directing the future of radiology. Many of these radiologists have outside ventures and partnerships with various companies and academics centers since they do not only occupy themselves with the standard day-to-day role of reading films. Some of the associations may be based on their research or area of expertise.

The higher-up academic radiologists manage their staff as chairmen. These individuals may be responsible for budgeting, hiring, and firing depending upon the institution. Again, your mileage may vary depending upon the role that you have in the institution. The almighty dollar has less control over your day-to-day work. (Although many would say it still plays a nice-sized role!)

The Pure Private Practice Model

What about private practice? In general, private practice wants to maximize income and the number of patients that go through your system. Of course, excellent radiology businesses have an element of quality. But quality exists to increase profitability, and the almighty dollar tends to rule the day. And, of course, all roads lead back to the almighty dollar. Employees and owners grind out films daily, day in day out. The philosophy: if you do not work, you do not make money.

Now, of course, the private practitioner also accomplishes other activities in trying to make money. These folks may perform some or all of the following practice needs: advertising, buying and selling equipment, strategic partnerships, and mergers, maintaining relationships with hospitals, hiring and firing an army of numerous employees (possibly radiologists, technologists, janitors, nurses, physicists, and so on), maintaining and purchasing real estate, payroll, billing, legal issues, parking, and utilities. On the other hand, academic hospitals/ institutional facilities typically take care of most of these issues. Therefore, you need to enjoy playing many different hats and roles and being a self-motivated entrepreneur.

The Hybrid Private Practice/Academic Model

I currently work in this role. I like to think that I get the best of both the private practice and academic world. (Although some would like to say that is the worst!) The hybrid practitioner’s philosophy: A dabbler who enjoys elements of both private practice and academia, but not in such depth.

So, how does the hybrid model work? First of all, you have a few variations on a theme. In my situation, I am involved in a hospital-based private practice with a residency program and multiple covered hospitals and imaging centers. For another type of system, the hospital may employ you, but the hospital may tie you to the private practice world via output bonuses. In essence, the practice expects you to teach, do a little bit of research, and maximize your work output. Thereby, you create income by grinding through studies. Most of these practices are not involved in purely academic activities such as obtaining grants. And, you will probably not involve yourself in typical pure private practice issues. For instance, you will probably not need to maintain the building utilities.

The hybrid practitioner/dabbler likes to do a little bit of everything without delving into some hardcore academic and pure private practice issues. I was never interested in writing grants, but I certainly wanted to teach. I was not interested in dealing with some of the fundamental problems of private practice, such as hiring/firing technologists. Yet, I was interested in the mechanics of business and private practice. For the sort of person that likes to be a bit more generalist, the hybrid model can be a great career path.

How To Make The Final Choice?

I think the final choice becomes a personality-based thought process, not one based on the different income constructions of each career model. If you hate business in all forms, work for the government or academia. If you hate writing and teaching, a private practice may be for you. On the other hand, if you love doing a little bit of everything, think about the hybrid model. Bottom line: You need to be true to your self. Do what you like, not what others will think you will enjoy. If you follow these precepts, you will make a great choice and have a fantastic career!

Comments are welcome!!!