I have just returned from the Midwest and learned that new graduates from three-year residencies are able to demand much higher salaries than when I graduated from my two-year residency in 1993. I am talking a huge difference that made my head spin!

When I graduated in 1993, it was not unheard of for me and my colleagues to be offered salaries of $40 and $45,000. We, of course, were not happy about it and we definitely felt used and felt absolutely not loyalty to our employers. Usually these first employment situations were just temporary before we went on to a second location that was usually a more longterm situation.

In the midwest I learned that some of my former students from DMU/CPMS were getting contracts in the neighborhood of $150-!75,000. One of them asked, brazenly, for a contract in excess of $240,000 but was not successful.

Is this the norm these days? It makes me want to go back through residency! Believe me, I think that if you spend three years of advanced training, and if you do an additional one year of fellowship, you probably deserve a handsome salary.

What I DO know is that we certainly deserved more than the $40K that we got back in the 1990's and I imagine those DPM's who gave us those rotten salaries are probably reaping the outcome of giving people those lousy salaries of working new graduates into the ground.

Kathleen,

Salaries are usually based on market forces, and of course, geographic distribution of the country.

Here in Florida, because the population is heavy Medicare and managed care, the starting salaries are much less than those who practice in urban northern populations.

PM News' annual practice survey does a very good job at isolating the geographic and respective salaries for new graduating DPMs.

And of course, thanks to Barry Block for giving us such a forum to collect and review data.

Eric 

I think it depends on many factors.  A straight salary should be in the $110-120k range for new graduates.

An associate with an incentive plan may make $80k + incentive (and hopefully it is an attainable goal that is set).

Regardless, new graduates have ~200k in debt.  Anything less than a 6 figure earning is cheating them and perhaps too little to live on. 

I am afraid there is a huge gap between what the new practitioners WANT and what they actually COLLECT. If you are fresh out of the residency program today, you will be one of the best-educated doctors in our history (thanks to the PRESENT!), but you won't have the business savvy or the billing/coding knowledge to make the best of it.

I would hate to burst the bubble & give reality checks for those students and residents reading here, but I think the standard rates for the new graduates would be 100-120k, or even MUCH less.

As mentioned previously, it would vary wildly depending on where you practice and what your practice (solo versus group, surgical versus primary care, academic versus private practice).

By the way, I was listening to Dr. Harry Goldsmith (coding guru)'s recent lecture and he mentioned that solo practice is going to be tougher and tougher in near future, due to the increasing demand to be compliant with the billing and coding requirements. We are also expecting the conversion from ICD-9 to ICD-10, which is scheduled in 2013 (I think). We already use ICD-10 in Japan, and it is much more complex and detailed than ICD-9 and we would probably have to overhaul the billing software for that process.

 

Kazu has a good point that should not be missed.  The days of practice, bill, and get paid are not as simple as they once used to be.  Just to get paid for what you do and not to over provide services that are not part of a patients insurance benefits is increasing difficult.

It is so important to know and understand the benefits and limitation of benefits of the individual insurance plans in the out patient setting.  Otherwise what you will encounter is a high monthly bill out which you at first become excited.  But your excitement will quickly turn to something else when you see a low patient  reimbursement per visit amount with alot of denials for  non-covered services, multiple procedure rules, global periods, bundled services, ect.

Karr 

I think the answer really does depend on where the new associate is going into practice.  As someone only in practice 4+ years, I feel like I can give my residents good advice as to what to expect in the region where I practice.  The people I work for have always been open with all financial practice information, which is also important in being able to asess this.  Based on what I collected in my first year, it seems fair for someone coming out in the Washington DC region to make at least 90K base plus an incentive.  But I can say that knowing what overhead is in our area.  In other regions of the country, I just wouldn't know.

Great topic Kathy!!

As a relatively new doc in practice 3 years I have a strong opinon about this.  My view is that podiatrists newly out of residency are grossly underpaid.  I remember reading an editorial in Podiatry Management Magazine where it was stated podiatry is the only specialty to start out at under less than $100,000.  I can't even think of ANY doctor - general practice or specialist - that makes less. 

I was once offered a "great deal" while I was a resident.  This podiatrist offered me a base of $50,000 with an incentive bonus of 30% after 3 x my base.  How ridiculous is this?  When I started in practice my base was much less than $100,000, but I managed to make 6 figures w/ my bonus.  

I may receive a lot of hate responses but from my experiences and speaking with MANY new doctors it seems like podiatrists simply underpay their new associates - no matter what part of the country they practice.  Why is Kathy's comment about starting low and then moving on such a common theme in podiatry?  We all hear stories about how expensive a new associate is to a practice, but I see this as an excuse.  If our more senior colleagues hired associates at a fair wage (perhaps $100,000 base) we would hear less stories like Kathy's. 

I made my first employer plenty of money.  At no time did he take a loss and I more than paid for my salary.  I'll bet this is common around the country.  Why is it that the statistics show a solo podiatrist makes less than 2 pods less than 3 pods, etc.? 

Some might argue about the training necessary for billing, practice management, etc.  I actually learned coding as a resident and knew more about coding than my boss when I was hired.  Granted this might not be common but perhaps it should become part of the resident curriculum.

Here's my suggestion to those pods who are thinking about hiring an associate:

1. Carefully examine your practice.  If the practice can't handle 2 docs then don't hire anyone. Think about WHY you're hiring that new doc.  Is it to allow yourself some extra personal time while maintaining the practice volume?  Is it enhance the practice?  Is it to hire a cheap workhorse?

2. Look for the best associate you can.  They should bring something unique to the practice.  Interview as many candidates as possible.  Look for the best match.  Go with your instincts; if they look lazy don't hire them.  That young doc should be hungry!!

3. Hire that new podiatrist at the best rate you can afford.  Treat them well with respect as an equal.  Mentor them so they can learn from your experience and improve our profession even more.

That's one young doc's opinion.  Treat that new associate like the gold they are and all else will fall into place.  It 's the best investment you can make in growing your practice.

It's not personal, but it's all business.

The practice income should be based on the patient volume and collection amount. If you are fresh out of a school, you have no source for the new patient referrals to the group practice that you may be joining.  

I think lower base salary (80-100-120k?) with incentives are perfectly fair solutions today. I am in a process of hiring a new doctor, and let me tell you, nothing is more "unattractive" than a new doctor thinking they are entitled to a gazzilion dollar salary in the first year. 

When I was a 1st year resident in Cleveland, I got paid $36,000 (the same salary as the MD resident counterpart), and I thought it was a lot of money back then. My first job was $60,000 plus incentives...not too long ago...just FYI.

This is fascinating. I know a national leader in our profession who recently tried to hire newly graduated residents in the Southwest for under $50K and little to no incentives with the promise of "getting you involved at the national level," which never happened.

That is despicable in my eyes. And it perpetuates the stigma that the modern podiatrists are trying to quash, thank goodness.

Fair pay for fair work. I have seen such loyalty when doctors are paid decent wages! Are we surprised? Of course not!

That is why I worked my  butt off for Dr. Harkless at the University of Texas Health Sciences Center at San Antonio. (My husband rightly says ' No honey, there is still quite a lot of it back there.') I worked at least 12 hour days at a minimum and 18 when I was on call, I slept on my office floor and received an award from  the residents for doing so!

I was willing to do so because the work fulfilled me, the pay was decent for academic medicine (always much lower than private practice) and I made additional money through lecturing and writing. It was enough and that is what I have always sought -  enough.

But I really have NO RESPECT for those in our profession who have used and abused the young practitoners with low salaries and long days. I know that their time will come as well and it will not be pretty.

I would agree that there are regional differences in the determination of associate salary, and i can't speak for other areas in the country, but I know for my co-residents graduating from our program in Washington DC, our starting salaries ranged between $75K-130K (with the potential for bonus in some instances).  All of us joined pre-existing practices; no one started out on their own, although i do know of several friends and colleagues from other programs who have done so.  For the most part, everyone that i know who've graduated recently have joined a group or bought into a practice....

It is truly amazing to hear how different everyone's expectations are.  Those of us who own our practices have a much different view than those who are part of a "group",  As far as I can tell, here are the major differences between WANTING and EARNING:

a)  New graduating residents have NO patient base.  They have skills, but have to be trained and taught how to think as a private attending, not as a resident.  This takes 3-6 months for them to learn.

b)  Employers need to learn to be flexible and patient with new graduating residents.  They are hopefully, "well-trained" and have earned the right to bring in new ideas and techniques.  This has intrinsic and extrinsic value to a practice, but how can one calculate that?  The answer is, you can't.

c)  There is a division between a graduating resident EARNING the right to ask for $120,000 + versus earning it.  I am absolutely in favor of paying them what the market bears, but I cannot as an employer, allow the new hire to bankrupt the practice just because they did ABC Residency and have a PM&S-36!!  There has to be some line of, "you've deserved the right to make this money now show me that you can earn it" needs to be a paradigm that employers must have on the table.

d)  Kazu hit the nail on the head:  New graduates have no compreshensive idea about practice costs, billing and coding, insurance, unemployment taxes, taxes, w-2 vs. 1099, overtime, salary, etc.  To ask for $150,000 without a base knowledge of how a practice works seems fool-hardy and to be blunt, "YOU HAVEN'T EARNED IT YET!"

Just my thought-

Eric

Eric,
Thank you for your candid comments. You are correct. Being in private practice, the buck really does stop right at your wallet, doesn't it.

From your perspective, in your market, what would you think a ballpark figure range would be for a new associate, coming right out of a 3-year residency program.

I agree that residents are often (not always) uneducated on the demands of private practice.  Perhaps more podiatrists in the real world should start demanding this as part of residency training.  Why can't practice management be incorporated into the curriculum? 

Having said that, we keep saying how these are the best trained residents ever.  I've said that myself.  If that's true, then they deserve more pay when they get into the real world.  To say I received a $60,000 base when I started so everyone else should is not fair.  Along that same thinking then, shouldn't it be OK for our residency attendings to treat their residents like dirt just because they were during their residencies?  Of course not.

As a hiring doctor you need to make sure that person you hire is as good as possible.  Do your homework.  Call those references.  See that resident in action if it's at all possible (which in most cases it is since I believe more than 70% of graduating residents practice within a short distance of their training program).  Interview them more than once.  Talk shop; find out their philosophy.  Can they really handle that Charcot foot or that bunion complication?  Discuss practice management issues and gauge their knowledge.  Can they code?  Do they know what E&M means?  Learn about them as an individual.  This should be a tough process.  If you don't do your due diligence then you deserve what you get.

When I mentioned a 6 figure salary I'm not saying $150,000.  I don't know exactly what fair is.  However, if you hire a good physician who's ready to learn, smart, and hungry they are going to pay back the investment with dividends.  I'm not sure exactly where the bonus scale fits in and how that should lower the base; I'm not positive what's fair to all parties.  I still see, though, EVERY OTHER SPECIALTY starting out above $100,000, even with a bonus scale.  Why are we different? 

My old boss did not work hard to teach me.  I was ready to learn as much as possible as quickly as possible.  He profited from me the first year out for many reasons.  I wanted to work hard, he was willing to mentor me to an extent, and we worked hard to expand the practice, besides the fact that he was busy enough for 2 doctors.  His practice was ready to expand and he had done his research and knew this. 

I made his life much easier also.  These are the "intangibles."  I took all the call for 3 hospitals except when I was on vacation.  This included his in hospital postops.  I handled all the hospital consults.  My boss was able to go on vacation (which he hadn't done for quite some time) and keep the office open.  We doubled the time his office was running by having a second doc.  I also helped improve his billing process by bringing information that I'd learned in residency.  I'm not trying to spout how great I am (far from it - I still have a lot to learn) but there are intangible benefits to that associate.  To say you can't calculate in direct dollars these intangibles doesn't mean you don't consider them. 

Hire that excellent new doctor after a legitimate interview process, pay them a REASONABLE salary +/- bonus and you'll have made an excellent investment.  Hire them for beans and you'll be looking for your next associate as soon as the contract is up.

Jarrod,

I can appreciate your aspect of thought process with how you were in your first job in Michigan.  You were lucky, you had a very understanding senior doctor who allowed you to grow into the podiatric surgeon that you are.  It also allowed you to make your mistakes and learn from them, so in essence, your last year was more like a fellowship (I know it was private practice, but it sounds more like a fellowship year).

Kathy, I am not sure what I would be willing to pay for an associate, but I know what I would start one at right out of residency.  I have that number in mind, but I can assure you it is less than 100k and more than 50k (do the math).  There would be heavily-laden incentives for performance, as I am taking a HUGE risk with the new hire.

The other aspect that nobody wants to mention here, is that the residents that graduate need to understand that they in the real world, have NO INTRINSIC value to a practice.  They in the most part, a massive EXPENSE that doesn't pay off until the 7th or 8th month.

As we all know, it takes time to develop a practice, and even longer if the area is heavily saturated.  The decision to hire an associate is a major one, and should EASE the burden on the hiring doc, but sometimes it doesn't.

Eric 

In response to:

"They in the most part, a massive EXPENSE that doesn't pay off until the 7th or 8th month."

- I have to agree with this.  As in any new investment there needs to be time to recup the invested dollars. 

Eric,

Good luck with your associate search.  I'm sure you'll find someone excellent!!! 

I have to add one other thing to my prior argument.  I wouldn't want to weaken it by arguing against myself, BUT:

About the salary...  My wife reminded me that salary was not the issue with my leaving my prior position.  In fact, I was about 6 months away from a partnership buy in when I left.  There were other reasons beside money that caused me to look elsewhere.  I have to acknowledge that.  My point here is that even with the best fit and circumstances that associate you invest money into may still leave.  I hate to say it but there it is.

Jarrod,

Funny how that now you are a business owner, you see things differently?

Being responsible for anyone is a large responsibility.  Add family, even harder.  Add employees with families, just add more logs to the fire.   It is very difficult in today's world to make money in practice with the narrowing margins.

Most graduating residents really have no comprehension of this concept.  It is as foreign to them as is Russian to me.

Do I believe that the residency programs need to include extensive practice management?  YES.  Do they get it? NO.

I know the AAPPM sponsors practice management meetings, but they are not always slanted to benefit the residents.  There really is no purposeful or useful resource....wait a minute...yes there is.....PRESENT PODIATRY!!! 

Alan, any way of creating a resident forum of REAL practice management tool-type lectures for residents in their senior years? 

The lectures can include:
a)  BASIC coding and billing
b)  Contracts
c)  Medicare system
d)  Private insurance system
e)  Associate vs. employer relationships
f)  How to interview and retain your attorney, accountant, etc.
g)  Which practice is right for you?

Just a few ideas...

Eric

AMEN!! The things that Eric just mentioned are those things that students and residents do not get in their programs. Hal Ornstein and the Practice group have made incredible strides to get there but they have not quite arrived. Management We all need more education in this area.

Residents graduate from their programs thinking that they are 'Golden' - wortth tons of money. I learned over the weekend that some graduating residents from a noted 3-year program cannot even do a hammertoe while others that have graduated from some Californa and DC programs can do advanced flaps, vascular reconstructions, ankle fractures and anything else that you can throw at them. Wow! What an incredible difference!

I would be wiling to pay $150K for the DC and CA residents but I wouldn't be willing to pay half that for the less well trained residents. I would look to hire residents who could pay off in my personal practice.

Why would I, as a business owner, want to hire someone who would not be able to perform with confidence? 

It makes no sense. 
           

Eric,

Great idea!!!  PRESENT lectures are an excellent way to improve our resident education in practice management. 

Alan, I think Eric's onto something!

Kathy,

I agree with you about not hiring a resident how doesn't have the training and confidence.  That's what the interview process is for.  A good, strong, comprehensive interview process should find you the best person for the job.  I too wouldn't hire someone who can do flaps and ankle fractures but not be able to fix a bunion or hammertoe.  If I were to hire an associate they would be sweating a little through my interview.  Not disrespectful, mind you, just comprehensive.  With this kind of business investment I want the biggest bang for my payroll buck.

I have been approached off-line to ask about the recent direction this conversation has taken.

To answer those people and others who haven't asked but wanted to know:

1. No, it is best that I not name the particular institution for a host of reasons primarily because I suspect that it is NOT the only residency program for which this can be said. Secondly, because I do not want to handicap these particular residents because they will already be handicapped enough and it is not their fault. 

2. It is not my alma mater, as you might have concluded, but another program that I was pretty familiar with and had friends who had graduated from - proudly and rightfully so.

Now, back on track - If a former top tier residency program is now producing 3-year trained residents (and of course this is, remember, hearsay, and I cannot verify it for myself) who are not comfortable doing a simple bunion, it behooves us all, as essentially CONSUMERS, when we hire new associates to do our own due diligence.

I spoke with Dr. Lawrence Harkless tonight about this very thing and the "hits and misses" we had made in our own careers when it came to interviewing potential faculty hires and resident "hires," and indeed selecting residents is a hiring process.

He said that all of the "mistakes" that we had made at UT with the hires that misfired, faculty and residents, could have been prevented if we had picked up the telephone and called five people who had known that person for a reasonable period of time. I agree with him. That would have prevented so many problems.

At the same time though he reminded me that everything that has happened, had happened for a good reason that we would not understand for some time. We are both people of great faith and we believe in the big picture.

If I was in private practice and the buck stopped at my wallet though, I’m not sure that I could realistically wait for The Big Picture!

Reading through these varied responses, it seems to me that there are essentially two issues in play here:

First, there needs to be greater standardization of residency training such that at a minimum graduating residents from any program should be competent to perform the most common 'bread and butter' types of surgical procedures (bunions, hammertoes, neuromas, etc).  There will additionally be a subset of residents who, by virtue of training opportunities, will be comfortable with more advanced reconstructive cases (or perhaps there should be funding to develop additional fellowships to allow practitioners who feel their residency training was lacking in an area of their interest to pursue more focused training in that area (such as reconstructive cases or limb salvage).

The second issue is one of value, or rather perception of value.  It seems, reading through this thread, that there is a disconnect between the value that graduating residents place upon themselves verses how employers view a graduating resident's value.  Both points of view have some merit.  Certainly a new graduate will have less to offer in terms of practice management (and it has been well discussed that residency training should be improved to allow greater exposure into this facet of medical practice), but a new graduate who is well trained can help a seasoned practitioner diversify the existing practice to incorporate the new techniques and technology that that new graduate can bring to bear.

Ultimately in this economic climate it is important that both groups work together.  As a member of the 'recently graduated' category, i can honestly say that these last five months have provided a significant 'education' in terms of practice management, but it has not been a one-way street.  The practice volume has significantly increased since my arrival, as have our surgical numbers, so i am learning 'the business' while do my part to help the practice succeed, and that is ultimately what each of us wants --to be successful.  No associate wants his salary to bankrupt the practice... but at the same time, you (and i can speak from experience here) recognize that your training has a certain value (because it is something that you have and they don't), and you want to approrpiately rewarded for obtaining that level of skill and training.

Ryan,

It was not my intent to subvert those graduating residents who have made impacts in practices like yourself.  However, most graduating residents do NOT find employment with multi-specialty groups or orthopedic aligned groups that are looking for a foot and ankle surgeon. 

The fact is, well over 90% of all residency grads look for employment as part of solo or two-doctor office situations where there is plenty of expectations placed on the new grad to bring in business.  There are of course, inherent problems with that dynamic:
a)  if the new grad is socially shy, tough luck.  Will be a tough 1 or 2 years to finish that contract and move on.
b)  if the employer does not take an interest in the new grad and introduce them to colleagues, referral sources, patients, etc, again, it will be a long contract period for BOTH parties.

Overall, the associates/new grads do eventually make difference in which ever practice they join: 

For the better, and for worse.

Adding to Kazu's comments --  having outstanding clinical skills plus a good understanding of reimbursement issues (maximizing revenue through correct coding, documentation, and compliance know-how) plus knowlege of practice marketing methods and a willingness to to out into the community to develop referrals for the practice -- hey, what employer would not want to give this DPM maximum salary?  We are in a recession, and the threat of reduced revenue due to healthcare reform measures looms ahead.  The new practitioner who has both excellent clinical skills and good practice management savvy is equipped to earn top dollars.

Larry Rubin, with his vast years of experience, is exactly right. When I was traveling around the country with the "Step into your Future" program, lecturing on practice management at the schools, I stressed the value of practice management skills in getting that first great job.  It's as rare today for graduating residents to open their own practices as it was common back in the 80s. The risk reward curve has reversed. They all seek jobs. The hiring practice isn't just looking for the new associate that brings new technical skills to the practice. They are looking for the associate that will GROW the practice, because if it doesn't grow, they are merely sharing revenue that they were trying to capture on their own, with another person.

For all of you sharp residents that are reading this, learn well:  It's as important for you to spend time in offices and learn how the business of podiatry works, as it is for you to hone your surgical skills. Ultimately, it is your ability to GROW the practice that you work in that will lead to success.

See Kathleen Satterfield's interesting new related Topic:

Before You Hire An Associate: WHAT ARE YOU GETTING FOR YOUR MONEY? 

in which she makes the point that the hiring doctor and the new associate should really work with each other for a few days to see if their values are compatible.  There is just so much that you can learn in an interview.   More good advice...

Eric,

You seem to lump all residents in together as one large group who can bring nothing to a solo or small group practice and are too lazy to work/too dumb to understand billing/coding.  As a soon to be graduating third year resident I beg to differ.  Many solo practitioners only do forefoot surgery or limited rearfoot/ankle. 

A well trained associate could add or keep a significant number of patients by adding a full scope to the practice.  New associates are often taken on due to an increase in business and they can help to ease this load and make your life easier.  I have nearly completed a high volume surgical residency and am very well trained in that respect, all while spending a good part of the past 5 months learning CORRECT billing/coding.  While we continue to have much to learn, we also have much to offer.  I would ask you to begin to judge each potential associate on their merits instead of implying none of us add value to a practice or deserve high salaries.  You would never dream of taking on an associate if you didn't think it would be profitable.  It's an investment, not a transaction, and to expect anything besides an immediate financial outpouring (investment) is extremely short sighted.  Also, why would I ever want to work for someone who thinks I bring nothing to their practice?  When I feel valued by an employer, I work harder to give back.

Almost every potential associate HAS EARNED a six figure salary/bonus by simply traveling the tough road to becoming a well trained foot and ankle surgeon.  I say almost because we're not all well trained.  We deserve to be paid well for our WORK...but the WORK part is the key.  A lazy associate will not make that much money with a proper base/bonus arrangement.  On the other hand, someone who works extremely hard, markets themselves well, and establishes him/herself within the medical community will be richly rewarded with the same contract.  Low base salary or straight salary contracts hurt our profession.  Here are my suggestions...

1. Every associate will have different abilities and work ethic.  Give us the opportunity to make as much or as little as we want.  I believe a base of $80-100K with 25-35% of collections over $200K is fair.  Straight salaries give no incentive to work harder.  Prospective employers should place marketing expectations in the contract to encourage success. 

2. A well trained PM&S 36 graduate deserves a six figure income based upon ability alone.  The financial liabilities we face after residency graduation demand this.   

3. If coding/billing is the major issue then start sending your new hires to AAPPM meetings/seminars prior to the time they start.  I hope to have a contract signed by the new year, which will leave me 6 months to focus on coding and billing before I begin seeing patients in my employer's office.  Soon to be residency grads should do everything we can to learn billing/coding during the time we have left.  If your hospital offers CME money, use it to educate yourself on this.

4. We understand all that goes into hiring an associate because we hear about it from attendings and potential employers all the time.  You wouldn't tell a Lexus dealer he's asking too much if you're only willing to pay for a Chevy.  You'll pay more for the Lexus, but you'll also enjoy the ride a lot more.  If you can't afford us, don't go shopping.

5. Three year trained foot and ankle surgeons should demand the realistic opportunity to make six figures.  Wish those who offer less good luck and move on.  They will get what they pay for in the end.

Just my humble opinion,

Pete Walimire

I am overwhelmed that there have been over 24,000 viewings of this topic, which indicates a definite interest in the topic.

Eric, I wonder where you got your statistics of "well over 90% of all residency grads look for employment as part of solo or two-doctor office situations." I simply can't see that being true today. I know of few residents going into solo practices anymore. They seem to be as rare as hen's teeth now. I would be interested to know where these stats come from.   

I certainly can't speak for every recent graduate, but i can tell you in my graduating class, only one (of four) of my co-residents joined a practice with two or fewer pratictioners.  I would indeed be curious to know what the overall trend is in current graduates with regard to what kind of practices they are looking for....

As a current third year resident at a multispecialty teaching hospital with a broad spectrum of training from primary care, surgical training as well as office and coding/billing day to day application I appreciate the comments made with respect to blanket statements about outcoming residents not being valid. 

Speaking for myself and co-residents as well as podiatrists who completed residency over the past two years, salaries of 200k are not unheard of, and more appropriately the norm.  These jobs are not with other podiatry groups, mostly because of the discussions going on in this blog.  Podiatry groups seem to hire you with the only expectation of financial loss.  Asking you to sign contracts that have clauses dictating which patients you will see (this from personal experience).  Hospitals, multispecialty groups and orthopaedic groups hire you as an asset and member of the team of physicians.  Just as in other medical specialties they give you a competitive salary 150k + with an either RVU or production based bonus.  If you as a new hire are afforded the opportunity to build a practice and have a referral system the growth of a practice is inevitable.  The resident that graduated prior to me joined an orthopaedic group with 12 other physicians making a base of 200k+ and 50% of anything beyond his base.  Five months in he has already met his base and is now getting his above and beyond.  I will add that this person is extremely hard working and very personable- two important qualities that allow the growth and so quickly. 

These things stated, if we have been trained for 3 years and some of us even with fellowship training and aren't learning the things key to growing a practice... then why are we sticking around the extra time.  Yes this is to increase our surgical numbers, but more than anything you begin to really understand the inner workings of practice.  At my residency program we see patients start to finish both from conservative and surgical treatment.  We also code each patient we see- now independently.  Of course if there are questions, we ask or we know how and where to look for the infomation.  I personally feel confident that I will hit the ground running in 6 months and be a true asset and not financial loss.

As we train alongside MD/DO physicians and rotate on the same rotations they do and work the same hours they do and more than anything as a profession want to be considered equal and paid for our skills and training level on an unbiased ratio.... why then can't our own predecessors see us as such and treat us accordingly. 

Sorry everyone, I have been out of the loop for a while, (another back surgery....)

Give me  a moment here to clarify my comments that everyone is so gnawing at....

I may be overstretching the "90% of all residents..." comment, I will agree to that.  There is SOME percetange, that all of us would agree, that graduating residents are more likely to find employment with a single or two to three physician group practice than an orthopedic group or multispeciality clinic.

With my comments as to most graduating residents have NO idea about the business of medicine, please allow me to elaborate:

I recently discharged an associate (yesterday) who simply did not get it.  This particular person was seeing patients, did a decent clinical job, took care of the patients.  The patients liked the practitioner and I had very few negative comments or complaints.  However, this is where the "good" stuff stops.....

Over the last 8 or so weeks, I have been attempting to instruct my new associate about the "game" of documentation.  I basically have a core instruction workbook that says what we all know, "if you don't write it down, you didn't do it".  As I would train my associate in my EMR system (Medinotes), they were provided the instruction guide book (which I made) with a link to the AMPA Coding Resouce online service (which is awesome, btw)

I worked with my associate to learn the EMR system.  This is where things got rocky.  They REFUSED to do charts on the EMR.  I would come in the next day, and all the notes were handwritten and the visit was not coded properly.  Of course, I wasn't too happy about this, so we sat down AGAIN and I counseled them as to office protocols and that the medinotes system was the ONLY was patient visits were documented.  I was not throwing a lot of patients at my associate and scheduled enough time during the day for he/she to get the notes completed.  I was always on top of things but here is when it turned SOUTH:

Yesterday, in a meeting with my business manager and attorney, my associate stated that he/she  just wanted to see patients, bill the minimum visit and NOT DOCUMENT.  I asked my associate that  in follow-up visits, how do you know what you did last time, and they said "I am WINGING IT, that's how we do it in residency".  Of course, I had no choice but to terminate the services immediately.

My point in earlier posts is that there is NOT enough training in residency programs about the business side of medicine.  From charting to billing, to collections and insurance regulations.  There needs to be more on the business side of things becuase even though my associate was a 3-year very well trained surgeon/podiatrist, they were incapable of learning the business side of medicine nor wanted to.  The problem I have is that I took a risk, knowing the consequence of it, but what really bothers me more is the lost opportunity to mold and train a new podiatrist in order to make the practice stronger and provide more services to the community.

I hope everyone who reads this, both owners and residents and employees, understands that there is always a risk when hiring someone.  Some good, some bad, but in all, it wasn't my inability to train my associate that was the problem, it was this lack of initiative and discipline and work ethic that I feel is lost in today's residents.

Eric,

What an unfortunate situation.  It sounds like you did the right thing terminating the contract.  I don't think, though, that this person would be indicative of the average podiatric graduate.  The issue sounds more like an ethics/personality deficiency.  It's one thing to have difficulty adapting to the requirements of our medical system (documentation, coding, etc.) but to REFUSE?  That's another issue entirely!  This person is beyond a liability for any practice unlucky enough to hire them.  Good luck with your search for a replacement.

Eric - That is great argument and favors a highly incentive based contract.  A reasonable base salary will show  a level of commitment from the employer, satisfy the employee and provide a strong incentive to bill and document well!  I would have to agree that many of my peers are more concerned about a "base" guarantee then they are about incentives.  I for one am much more concerned about incentives and bonus.   You should trust your employer and if you do you should have no problem accepting a small base salary with good incentives.  The problem we new grads face is finding a trustworthy employer.  This is very difficult particularily here in Michigan. 

Kathleen,
   good topic. and good to find you here at Present.
   I graduated in 1998, did 4 years of intense residency training (PPMR and PSR 36), and became board certified both in foot and rearfoot/ankle. I started at 50K base and commission after earning 3X salary when I joined an older Pod. After 2 years I was earning about 150K but his buy-in for the practice was about 350K'; therefore, if I decided to "buy-in" I wouldn't have much money and he was banking on me buying him out (another six figure sum) when he retired.  He didn't show any desire to retire.
   We had major differences in practice style, documentation, and I ended up doing a fair amount of revisional surgery (which wasn't all mine). I was concerned if he (we) ever got audited and quit paying anything other than the "buy-in" required amount. 
    He made more than 1 million off my labor and was able to upgrade his office software, computers etc. He only hired one additional staff.  He did VERY well with hiring me.
    As of 2007, I've started my own office and make a good salary, have my own 401K for retirement, and three of his best staff came with me.  I'm in the process of starting a second office and wish I'd done this on my own a few years sooner.
    Does anyone know good books/info on hiring a new associate?  I've joined the AAPPM and attended my first meeting last year.  I'll be looking at their organization for some help.  I'm going to be in the market for an associate in approximately one year.
   PS.  Kathleen,  would you like to come back to lecture for the Oklahoma Podiatric Medical Association...I'm still the Scientific Chairman and can arrange that.

Hi Darren,
So sorry to be late in responding. I will contact you personally to explain why.

I am sorry that you experienced what so many of us have experienced in the past. There is definitely a learning curve to these things. The people who are bringing us into their practices do not think we are worth what we know we are worth.

Eventually, twenty years from now, we probably won't think the "new kids" aren't worth what they think they are worth.

WAIT A MINUTE!! Maybe we will think they are worth that.

Why? Because we went through the rigors of what we went through. And it just right.

We added hundreds of thousands of dollars to our partners practices. And in some cases, as Darren said, a Million Dollars and more. It just isn't right and we won't stand for it any more.

Yes, it will take a few thousand dollars out of our pockets but our generations are different. We know the difference from ight and wrong, don't we.