New Grad ER Offers (Comparison)

[ofa2322]

Hi everyone,

I'm a new grad fortunate enough to have 2 ED offers on the table. For reference, these are in NY (not in the city), within an hour of one another in a moderate cost of living area. My career goals are seeing sicker patients, trying to get in on more advanced procedures and making myself as marketable as possible in EM, eventually hoping to break into rural/solo ED coverage down the road. I'm indecisive thus far because each of these offers seem relatively fair but each position certainly has its pros and cons. I'll try my best to highlight them below and would appreciate hearing what you think of the offers and which you think would be better for my future development.

 

Offer 1: Metropolitan Area 50k annual volume, 40 bed ED, Physician and APP coverage all day/night

Base: $60/hr  - -> 1872 hours/year = 112k + $11/hr differential for nights. Additional shifts paid at same rate (is this standard practice?)

Shifts: 8 and 10 hour shifts only (I prefer 12s) - no night obligation until a few months in. 2 weekends/month

Scribes: One for each physician/PA team

Acuity: 40% admission rate (lots of sick folks). Spend most of time in main ED but eventually some shifts with provider in triage system. 1-1.5 patients/hr

Training: 6-8 weeks as additional provider. Able to do advanced procedures (centrals, intubation, conscious sedation) with SP observing when I feel comfortable doing so.

CME: $1500 (can use for licenses but no separate coverage for this)

PTO: 108 hrs/year

Business expense reimbursement account: $2000/yr 

Medical/Dental/Vision: PPO ~250/month premium, dental and vision ~30/month premium

Malpractice: Claims with tail covered by employer

Noncompete: only for same specialty in same hospital

Bonus: No regular bonus. 4% retention bonus given at 18 month mark and then yearly.

401k: 3% match on 6% contribution. Vests 25% per year of service.

Pros: Pay the same during training period (not what was said in interview but my contract doesn't reflect a decreased rate). Able to see most acuity levels with exception of arrests, newborns, STEMIs. No residents. 

Cons: Above would be main site but expected to work at 2 other EDs as well for same rate of pay. No psych or trauma coverage. 

 

Offer 2: "Rural/Suburban" Area 30k annual volume, 15 bed ED, 2 Physician and 2 APP coverage all day. No APP shifts overnight.

Base: $55/hr - -> 1872 hours/year = 103k - Additional shifts paid at same rate. 6 paid holidays (if worked, earn 2.5x normal rate)

Shifts: 10 and 12 hour shifts only. Split between ED and urgent cares

Scribes: None

Acuity: 18% admission rate. Spend half time in main ED and eventually some shifts with provider in triage system. 1.8-2 pts/hr.

Training: 3 month "fellowship" as additional provider at half pay. Able to do advanced procedures (centrals, intubation, conscious sedation) and get credentialed to do so on own.

CME: $1500 (can use for licenses but no separate coverage for this)

PTO: 144 hrs/year. 36 hrs extended sick leave.

Medical/Dental/Vision: PPO ~160/month premium, dental and vision ~7/month premium

Malpractice: Claims with tail covered by employer

Noncompete: None

Bonus: None

401k: 3% match on 6% contribution. Don't receive until after first year. Automatically vested at that point on.

Pros: Able to do get credentialed in advanced procedures. Extended training time. Closer relationships with other providers. No night shifts.

Cons: Half pay during training. No pulmonary or neuro coverage (telemed only). After 6 months of ED work, expect ~2/3 of shifts to be worked as solo provider in urgent cares nearby.

 

I think if the more rural ED was strictly for EM coverage and didn't include solo urgent care coverage it would be an easy choice as I could accept the hit in pay since there is a better benefit package and probably a better learning experience to be had. However, I am concerned this may turn into a strictly urgent care position which doesn't align with my goals and I'd hate to leave the job early because of it. Either way, appreciate your perspectives!

[MediMike]

Yeah what you said. What's the point of all this investment in learning and advanced procedural skills of you're going to get shoved into an UC for 2/3 of your shifts? Plus the whole half pay thing is kind of obnoxious, unless it's set up as a true "fellowship" as in you get didactics, off service rotations etc then all you are is cheap labor.

Expected PPH for #1 is great, sounds like they let you start slow and work your way into it. CME is a joke if they don't cover licenses, DEA etc, I'd try to negotiate that. Also 8s and 10s do suck. I'm sorry.

[Colorado]

On 4/9/2019 at 3:01 PM, ofa2322 said:

Hi everyone,

I'm a new grad fortunate enough to have 2 ED offers on the table. For reference, these are in NY (not in the city), within an hour of one another in a moderate cost of living area. My career goals are seeing sicker patients, trying to get in on more advanced procedures and making myself as marketable as possible in EM, eventually hoping to break into rural/solo ED coverage down the road. I'm indecisive thus far because each of these offers seem relatively fair but each position certainly has its pros and cons. I'll try my best to highlight them below and would appreciate hearing what you think of the offers and which you think would be better for my future development.

 

Offer 1: Metropolitan Area 50k annual volume, 40 bed ED, Physician and APP coverage all day/night

Base: $60/hr  - -> 1872 hours/year = 112k + $11/hr differential for nights. Additional shifts paid at same rate (is this standard practice?)

Base pay is average. Not stellar but not low. Depends on the market. Yes, you could probably find a higher paying job in a rural or less desirable market. If this location is geographically where you want to be, then pay may be your compromise.

Shifts: 8 and 10 hour shifts only (I prefer 12s) - no night obligation until a few months in. 2 weekends/month

I used to think 12s were the end all be all but keep in mind they are LONG shifts esp. if you are busy. Pro is 4 days off, but honestly at my job right now I work outpatient family practice and have 3 day weekends which is really nice AND I have time after work on my work days to still enjoy some life (ie: gym session, a run, dinner with friends/family) Some food for thought. If you really want 12s and its extremely important to you then this may be more of a drawback for you.

Scribes: One for each physician/PA team

Cool that your team has scribes, but HOW do they determine who gets the scribe if you're both working at the same time? Id wander a guess that the scribe will end up with the MD more often. I'd ask them about this. Is there voice recognition software? 

Acuity: 40% admission rate (lots of sick folks). Spend most of time in main ED but eventually some shifts with provider in triage system. 1-1.5 patients/hr

Training: 6-8 weeks as additional provider. Able to do advanced procedures (centrals, intubation, conscious sedation) with SP observing when I feel comfortable doing so.

I had a prelim offer from a group that offered 3 months training, not including also sending you to EM Bootcamp course during your first year (time and money not taken out of your CME or PTO) as well as interview for a group that pairs you 1:1 with another PA for 6-12 shifts then you fly on your own. So it all ranges. The more training if you're a new grad or new to the specialty the better.

CME: $1500 (can use for licenses but no separate coverage for this)

As a New Grad, this amount of money will easily chew through licensing, DEA, and any materials you want to have for work (new stethoscope, a reference book, subscriptions to AAPA/state chapter/SEMPA fees, and UpToDate etc. I would push for more money or make the caveat that 1500 is okay for this first year but you want Licensing fees, UpToDate(etc.), and 2 professional organization subscriptions covered separately by your employer. Find out what they offer the physicians and argue for similar. If they're covering the physician's licensing/professional memberships in addition to giving them 1500, you should have the same. If you travel to 1 conference (lodging, travel, conference fees) thats enough to eat up most of that 1500 per year, not to mention other CME you'd like to do (ATLS if you dont have it, CAQ, etc.)

Also, do you get CME TIME OFF in addition to your PTO? If not, your 2 weeks of PTO can easily turn into 1 week PTO if you spend most of a work week at a larger conference. CME should come with time off, esp if youre working 4-5 days a week.

PTO: 108 hrs/year

Based on 8-10hr shifts, this is only ~ 2 weeks per year. Low. I strongly believe the professional minimum should be 4 weeks but I see alot of 3 week PTO offers during the first few years of employment (ie 0-3). Counter with 4 weeks. Esp if youre working 4-5 days a week in the ER, you need that time off. Consider accepting 3 weeks if the rest of the offer looks good and you really want to be there.

How/how much do you acrue sick time? Is sick time addtl ontop of PTO?

Business expense reimbursement account: $2000/yr 

Ask what you can use this for. See above comment on CME money.

Medical/Dental/Vision: PPO ~250/month premium, dental and vision ~30/month premium

Normal. If you have specific providers (ie: my family has a specific orthopedic surgeon that we are midway through multiple surgeries with) that are important to you, check to see if they are covered by the plans.

Malpractice: Claims with tail covered by employer

Good. Whose the malpractice company or is it FTCA? What are the limits? Should you be buying additional insurance and if so, are you allowed to?

Noncompete: only for same specialty in same hospital

I hate all non-compete but this seems pretty lenient. For how long does the noncompete last?

Bonus: No regular bonus. 4% retention bonus given at 18 month mark and then yearly.

Understandably you may not be that productive for them during the initially. But you could counter with the pay raise at 12 mo instead of 18. 

401k: 3% match on 6% contribution. Vests 25% per year of service.

3% match on what the employee contributes is only average. Is there any additional match options?

Are you vested at 25% on Day 1 of employment or after completion of the first year? Its good that its not a cliff vesting schedule (meaning you dont get anything until X # of years and then 100%) but it will take you 4 years to be fully vested. Do you plan on being there for 4 years? The nice thing is that its gradually vested which means even if you leave early, youll get to keep some of the money the employer has contributed. 4 years to 100% vest is average (range typically 3-5yrs for most)

Pros: Pay the same during training period (not what was said in interview but my contract doesn't reflect a decreased rate). Able to see most acuity levels with exception of arrests, newborns, STEMIs. No residents. 

I feel like residents can be a catch 22. Ive had great interactions with them but they tend to take most if not all of the advanced procedures. I think its GREAT that you will be able to do these at your job.

Cons: Above would be main site but expected to work at 2 other EDs as well for same rate of pay. No psych or trauma coverage. 

1. How far is each site from your home?

2. They should be providing travel reimbursement for travel to any other site besides your main site. They should be reimbursing you for the ENTIRE driven distance between your home and the other 2 ancillary sites not just the difference between those commutes and your normal commute. Same goes for travel to those sites for any meetings, trainings, etc. required by your employer outside your primary site. The rate of reimbursement is typically determined by the federal govt currently at a cents per mile rate.

Offer 2: "Rural/Suburban" Area 30k annual volume, 15 bed ED, 2 Physician and 2 APP coverage all day. No APP shifts overnight.

Nice to have 2 physicians and 2 APPs all day. Nice no night shift (unless your a night person and really looking for night differential) Ive seen some ERs without the volume ($$) to support that many providers cut back to 1 physician and 1 APP in scenarios like this (15 beds) 

Base: $55/hr - -> 1872 hours/year = 103k - Additional shifts paid at same rate. 6 paid holidays (if worked, earn 2.5x normal rate)

Addtl shifts paid at same rate...boo. I have a current potential offer with the same offer for addtl shifts. I'd hate to see emed move more in this direction. Push for at  least 1.5 x pay for addtl shifts. What do they offer the physicians for addtl shifts?

Shifts: 10 and 12 hour shifts only. Split between ED and urgent cares

Theres the 12 hour shifts that you like. Even with 10s, you;ll have 3 days off and time after work to do something.

Scribes: None

What EHR do they use? Do you have experience with it? Do you have training specifically on it and someone in IT who you can turn to for help? Get your hands on the EHR system ASAP if you take the job and start making macros shortcuts etc. to make charting easier. Have templates for everything, theyll save you so much time. Prioritize this and get it done before you have to be on your own at work.

Acuity: 18% admission rate. Spend half time in main ED and eventually some shifts with provider in triage system. 1.8-2 pts/hr.

Do you want to be in urgent care? Sounds like you may be spending half your time there. Is it located in the ER with access to the same resources or is it separate?

Training: 3 month "fellowship" as additional provider at half pay. Able to do advanced procedures (centrals, intubation, conscious sedation) and get credentialed to do so on own.

I also hate this "training pay" concept. Not once in my life at any job have I been offered "training pay". They should be paying you 100% of your rate and if they feel that you are doing an exemplary job after 3, 6, 12 etc. months, then your 3,6,12 month review should reflect a bump in your pay. Id say, $55 per hour for the first 3 months then $60 per hour after that. If they wont do that and you really REALLY want this job, consider $50 per hour for the first 3 months then $60 per hour after that. Dont accept $25 per hour. The line cooks at my local restaurant make that without any formal training and just a GED/HS diploma. (yes, they are paid well for cooks, but its a high COL town where the lowest priced house is 700k for a 1000sqFt 2 bed 1 bath on a city lot)

CME: $1500 (can use for licenses but no separate coverage for this)

It should go without saying that 1500 CAN be used for licenses. See my comment on the other offer for more. My comments are the same here.

PTO: 144 hrs/year. 36 hrs extended sick leave.

Better than the other job it looks like, about 3.5 - 4wks.

Medical/Dental/Vision: PPO ~160/month premium, dental and vision ~7/month premium

Little cheaper than the other offer. Compare the plans, make sure they work for you/your family. What are the max out of pocket, deductible, providers in network, penalty/coverage for out of network, and avg costs you expect to endure.

Malpractice: Claims with tail covered by employer

Noncompete: None

Good.

Bonus: None

Ask yourself, if youre extra productive and efficient, who is reaping the financial benefits of your hard work? IF youre not getting a bonus for this extra effort, then your employer is making that extra money off your back. So whats the incentive to work hard?

401k: 3% match on 6% contribution. Don't receive until after first year. Automatically vested at that point on.

Whats the vesting SCHEDULE and %? Is it 100% immediately on your 1 year anniversary or gradual?

I think not offering a match the first year is poor form but more and more employers are choosing to do this. Are you allowed to contribute to the account during the first year or do you have ZERO access to contribute even your own money the first year? If they dont even offer the retirement plan to you until after 12 months, but its matched with 100% vestment starting month 13, then thats better than nothing and you could always open an IRA and contribute to that during your first year, then contribute to the matched 401k plan starting in year 2.

Pros: Able to do get credentialed in advanced procedures. Extended training time. Closer relationships with other providers. No night shifts.

Cons: Half pay during training. No pulmonary or neuro coverage (telemed only). After 6 months of ED work, expect ~2/3 of shifts to be worked as solo provider in urgent cares nearby.

Urgent cares tend to be lucrative for employers.  Would they at least give you a bonus for that portion of your job?

Again, do you want to work solo in an urgent care for 2/3 of your workdays? You will first and foremost be working as an Urgent Care PA, not an emergency medicine PA from the sounds of it. Is there opportunity to work FTE or 2/3 time in ER in future? 

I think if the more rural ED was strictly for EM coverage and didn't include solo urgent care coverage it would be an easy choice as I could accept the hit in pay since there is a better benefit package and probably a better learning experience to be had. However, I am concerned this may turn into a strictly urgent care position which doesn't align with my goals and I'd hate to leave the job early because of it. Either way, appreciate your perspectives!

Good luck. I work in FP right now and searching for Emed jobs. I have multiple friends (physician and PA) that are in Emed whom Ive had lengthy discussions about alot of this with. My comments are food for thought and in no way should determine your choice. Figure out YOUR priorities and find a job to match them. It doesnt have to be a job that matches them from now to retirement, but at least fitting of your current goals and priorities for the next few years.

[ofa2322]

On 4/14/2019 at 11:19 AM, Colorado said:

Good luck. I work in FP right now and searching for Emed jobs. I have multiple friends (physician and PA) that are in Emed whom Ive had lengthy discussions about alot of this with. My comments are food for thought and in no way should determine your choice. Figure out YOUR priorities and find a job to match them. It doesnt have to be a job that matches them from now to retirement, but at least fitting of your current goals and priorities for the next few years.

Hey, thank you for the thought out reply and for taking the time to write that all out, it has been a huge help for me! I have since started negotiations for the first offer and found out some more info and I think it has become pretty reasonable. I will post the specifics below more as reference for anyone out there that could benefit from the comparison. I will plan to post more about the second offer as it becomes available.

Offer 1:

• I have since asked for $65/hr (but expect a couple dollars more at most)
• For all intents and purposes I anticipate not having a scribe and if I do have an even split with the doc, it will be a welcome perk. Dragon dictation software is provided thankfully.
• EM Bootcamp provided free before start date and requirement of employment
• Business expense account of $2000 covers additional CME, organizations, equipment, travel etc
• PTO increased to 3 weeks. No additional sick time.
• Noncompete at same ED lasts for 12 months after termination. Hopefully will be a non-issue.
• 4% bonus is paid as a lump sum regardless of productivity. Can renegotiate @ 1 yr for base pay increase
• 401k vests 25% after first year
• Other sites will likely be an additional 15-20 minutes from home. Travel expenses are reimburseable through the expense account per IRS regulations.