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Rhematology vs. Internal Medicine Offers...Please advise!


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Hello, I am a new graduate and I have two offers. Both have significant pros/cons, and I am having a hard time deciding which to take. I am single with no dependents. I would really appreciate anyone's wisdom, advice, opinion on any of this.

 

#1: Rheumatology in a low cost of living city. This is private office practice with a single doctor who really wants to hire a PA to help with his patient load. The doctor is the most compassionate doctor I have ever met and would be a pleasure to work with and learn from. He said he would see all the new patients and I would see follow-up patients.

 

(This is how it stands before negotiation. I'm sure they would negotiate with me)

 

*1 MD

*2 year contract

*Hours: 50 hours/week; M-F 8AM- 6PM. Maybe some Saturdays-- but would add up to 50 hours.

*Starting salary: $92,000 

*I would train with the doctor for 3 months before I would see my own patients. During this time, I would be making $46,000. I know this is less than ideal for me, but I am not sure it's unfair since I won't be contributing to the practice during that time. 

*They will pay for me to take an online rheumatology course 

*Automatic 5% salary increase after one year. 

*4 weeks PTO including sick leave. Unused PTO rolls over to the next year.

*Paid holidays (the office is closed for more holidays than the average office including the entire Holy Week for Easter and the day before, day of, and day after major holidays)

*1 week for CME

*5,0000 for any CME, classes, licensure, association dues, etc

*Basic medical insurance-- great plan with no premiums

*Malpractice insurance covered

*Bonus based on each patient seen per week in excess of 75 patients per week (prorated for weeks with holidays, PTO, CME, etc)

 

Pros:

The doctor is awesome and very willing to teach/train me. I know he would be really patient with me and has a "Let's learn together" philosophy

Low cost of living

Very good treatment of employees

Very patient-centered practice

The compensation/benefits

I would get to spend more time with patients (45 min/patient). Is this the norm in rheumatology? Or is this more time than is usual?

 

Cons:

The location (climate is not my favorite, kind of isolated, lack of things to do, probably will be harder to find a strong community/make friends)

Might not be as marketable if I want to switch into primary care or a different specialty later

The specialty might not be as conducive to my longterm goals as internal medicine would (example: Peace Corps requires 5 years experience in primary care to be considered)

Only one provider (the doctor) to learn from. He's also never had a PA before which I actually think is good for me.

He does see a lot of fibromyalgia patients; I know this would probably be draining 

Rheumatology is really complex and I'm not sure if I need a strong background in internal medicine first to be successful

 

 

#2: IM/FP Clinic in Colorado

 

(Also before negotiation, although I don't think this practice will be as willing to negotiate with me)

 

*Has 9 MDs, 6 PAs, 2 clinics, expanding practice

*2 year contract

*Hours: 40 hours: M-F 9AM- 5PM. I would work every other Saturday from 7AM- 2PM but then I would be compensated with a 3 day weekend every other week. 

*Starting salary: $88,000

*I would train with the doctor for 3 months (making $50,000 just during that time) then start seeing 1 patient q30min for 4-6 weeks, then 1 patient q15min. These can be BP checks, med refills, and for complex patients one of the PAs told me she will discuss 15 minutes worth and then schedule the patient for another appointment to discuss the rest if needed. They also allot 30 minutes for physicals, pap smears, hospital follow-ups, and new patients. There are also six 15-minute blocks on the schedule to allow time for charting. One of the new PAs said she's never seen more than 24 patients in an 8 hour shift so far. The maximum possible is 28 patients. Is this reasonable?

*Sees all insurance types: medicare/medicaid, commercial, self-pay

*5 mile non-compete clause

*Health/vision/dental insurance

*PTO: 2 days PTO after 6 months of employment, 2 weeks PTO after 1 year of employment (dismal, I know)

*1 week CME after 1 year of employment

*$1500 for CME

*Malpractice insurance

*401k with no match

*$2500 moving allowance with a 3 year commitment 

 

*Most common diagnoses include: Diabetes, HTN, hyperlipidemia, UTI, URI, hypothyroidism, arthritis, depression, anxiety, chronic pain, pericarditis, uveitis, nephrotic syndrome, Sjogren's, temporal arteritis, lyphoma, parasites. 

 

Pros:

LOVE the location (Strong community/easy to make friends, tons of things to do, the mountains)

The internal medicine would be really valuable, as I would like to build a wide knowledge base as a new grad. I have future goals that require 5 years experience in internal or family medicine

More procedures involved (suturing, I&D, punch biopsies, joint aspiration, joint injections, casting, toe nail removals, etc)

Also has a good doctor who likes to teach new grads (he is a former medical professor), and I think the training is reasonable here as well

More providers to learn from/bounce questions off of

Tons of modalities available on-site (sleep study center, imaging, OB/GYN)

 

Cons:

High cost of living

More corporate/profit centered. They definitely care about their patients, but I don't think it's as patient centered as option #1.

They had 2 PAs last year leave the practice (one with no notice) for a different specialty...this made me nervous. I'm not sure if it's a red flag or not. Maybe he/she just wanted to work in a different specialty. Might not have to do with the job itself.

One patient every 15 minutes sounds like it would be definitely be more stressful. Being a new grad with no experience, I am kind of nervous about this patient load and hoping I will be able to be successful with this kind of patient load

Benefits aren't as good...the PTO is especially dismal

 

 

 

What do you think is the best move and why? Any advice, wisdom, thoughts would be greatly appreciated! :)

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My major concern is they both have training salaries!! "Starting salaries" aren't really "starting salaries" if they start you off on 50% pay!

 

Why are there training salaries like that? I think you can find something NOT a training salary.....

It's insulting to our profession, I think.... but that's just me! - more seasoned PAs, please weigh in on this one for me!

 

PTO and CME bennies on the first one are significantly better. But for reference, I made that "training salary" before PA school.....as I said, to me it's horribly insulting....

 

The second one - yeah NO! you get 2 days for a year? HA! (I would run from that one. sounds like they will work you like a dog. AND PAs just up and left? Danger, Will Robinson!) Not to mention that for a "high cost of living" area, they are willing to pay you crap for a training salary..... no. Just, no.

 

also, what KIND of malpractice insurance? important to know.

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My major concern is they both have training salaries!! "Starting salaries" aren't really "starting salaries" if they start you off on 50% pay!

 

 

 

 

Yes, I know that's not ideal and it does feel insulting, but I'm interested enough in these jobs to suck it up and do that if I have to. I can't see patients at all until I am licensed and registered with the insurance companies, etc. That process takes 3 months. Essentially, they are letting me start right away without licensure and will pay me half to just learn stuff without contributing to the practice at all. In fact, I would probably slow them down. If I had to wait for licensure, I would have to wait 3 months to start. 25$/hr is far better than $0/hr, right?  I'm not so sure that's such a bad deal. It also took me 6 months to get offers as good as these. If I were to try and find a job without a training salary, I would be out of a job for another 3-6 months possibly and I'm not willing to do that. 

 

Thank you so much for your input! :)

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The second one - yeah NO! you get 2 days for a year? HA! (I would run from that one. sounds like they will work you like a dog. AND PAs just up and left? Danger, Will Robinson!) Not to mention that for a "high cost of living" area, they are willing to pay you crap for a training salary..... no. Just, no.

 

also, what KIND of malpractice insurance? important to know.

 

I was definitely planning on negotiating for more PTO. I know 2 days is ridiculous, even 2 weeks is subpar.

 

I'm not sure what kind of insurance but I will ask. Thank you.

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The following things would cause an issue for me:

 

- 50 hours per week (recipe for burnout)

- 24-28 patients per 8 hour shift, 5 days per week (recipe for burnout)

- Training salary when you have a ton of debt from PA school

- 2 days PTO per year (recipe for burnout)

 

I work at an IM practice in a big metro area in Arizona. We've been looking for another PA (though I heard on Friday that we may have filled the position). I could ask if you'd like.

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The following things would cause an issue for me:

 

- 50 hours per week (recipe for burnout)

- 24-28 patients per 8 hour shift, 5 days per week (recipe for burnout)

- Training salary when you have a ton of debt from PA school

- 2 days PTO per year (recipe for burnout)

 

I work at an IM practice in a big metro area in Arizona. We've been looking for another PA (though I heard on Friday that we may have filled the position). I could ask if you'd like.

 

Yes please!! Feel free to PM me. If I can negotiate NM down to 40 hours per week, would it be a good offer?

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  • 2 weeks later...

Both of these offers seem a bit predatory to me.  You realize that 92k at 50 hours a week is 35$ an hour (less considering it is OT work.....). RNs make that much at good gig.  Unless that per patient bonus is gonna push you up to at least 10$ per hour it is still not a good offer.  Personally, I would keep looking seeing as you are not trying to get into a hard to work in specialty.  There a TONS of jobs offering better than this and you seem open to location/specialty

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NEVER sign up for a job with a training salary - nope no way

NEVER EVER

 

As for the offers - Rheum has schedule 50 hours per week - that alone would scream he wants to abuse you and make money off you while treating you like dirt.... (IMHO)

 

Ortho - well atleast they have you scheduled for 40....

 

 

PTO

NEVER take a job that does not have reasonable PTO - that eliminates Ortho offer

 

 

 

 

So

Salary for new grad

80-100k - NO training salary ever!

40 hour work week

CME 1500-2500/year

Full insurance package

PTO - 10+ holidays, 3 days CME, 3+ weeks per year, sick/personal 1 week

 

This is really the bare min package offer I would ever consider. I might be flexible on this on a give and take basis. ie only two weeks of vacation but only a 4 day work week that I could flex day off or something like that...

 

 

 

both offers stink for different reasons - keep looking....

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Hey ya'll so I got the rheumatology gig negotiated:

 

Low cost of living area

 

*100k with NO training salary

*40 hours/week

*4 weeks PTO, unused days roll over to the next year, +20 paid holidays

*1 week CME

*$5,500 for CME, licensure, dues, etc.

*Health insurance fully paid

*Malpractice insurance fully paid: claims made with tail

*Bonus per week in excess of 60 patients seen per 40 hour week (so that's if I see > 1.5 patients/hour)

*401k with 6% match

*5k relocation

*NO non-compete clause

 

Now what do you think of this offer?

 

How achievable do you think that bonus structure is with rheumatology patients? I know they are more complex so maybe I only will be able to see 1.5 per hour. Thoughts?

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That is a MUCH better offer. In fact for a new grad it seems great. I would consider it with my 2 years of experience.

 

I wouldnt count on much, if any bonus money that is production based as a new grad. That said, the offer is ok now even without bonus and as you grow you may start benefiting from it.

 

Congrats on standing up for yourself and negotiating. Imagine if you had just taken the offer as is!

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Hey ya'll so I got the rheumatology gig negotiated:

 

Low cost of living area

 

*100k with NO training salary

*40 hours/week

*4 weeks PTO, unused days roll over to the next year, +20 paid holidays

*1 week CME

*$5,500 for CME, licensure, dues, etc.

*Health insurance fully paid

*Malpractice insurance fully paid: claims made with tail

*Bonus per week in excess of 60 patients seen per 40 hour week (so that's if I see > 1.5 patients/hour)

*401k with 6% match

*5k relocation

*NO non-compete clause

 

Now what do you think of this offer?

 

How achievable do you think that bonus structure is with rheumatology patients? I know they are more complex so maybe I only will be able to see 1.5 per hour. Thoughts?

 

Well done

 

So this is a good lesson for everyone else - they (the employer) knows what we are worth - but they give that first crappy offer hoping to give themselves and extra 50k in their pocket by stealing it from you.......

Well done - learn what is reasonable, and stick to your guns!

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Thanks for all the input, guys! I really like the management of this practice because they are kind people and it appears they will value and treat me well here. I'm pretty thrilled with this offer. They're very family-oriented, so the office is closed for +20 holidays...I've never seen that before, but it's sweet!!!

 

But I do agree that this is a great example to always negotiate your worth...the first offer is almost ALWAYS a low-ball offer

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  • 2 weeks later...
  • 2 months later...

NewGradLyn - I'm a new grad as well. Awesome job negotiating! Do you have any tips to share? 

 

AlvernaHB,

 

My advice is do not be afraid to ask for what you want. Be confident and know your worth. Do your research, know the averages in each negotiation category, and know what to ask for in your specialty/location.  Also, you can think of creative ways to make the deal sweeter. For example: Let's say you are offered 1,000 CME and you ask for 2,000. If they don't give it to you, then you should ask them to pay 50% of any costs that exceed the 1,000. It's a compromise, essentially. So you can be creative in your negotiations. I also think you will have more power in negotiations if it's an area that has a provider shortage (ie. New Mexico). I think that certainly played a strong role.

 

P.S. I love this job, and my employer treats me very fairly/kindly. I really love the doc I work with and I have been seeing about 10 patients/day. And they buy me lunch every day for goodness sake :) They are very appreciative that I am here. Best decision ever to take this job!

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