physassistww Posted July 27, 2021 Share Posted July 27, 2021 I need advice about a situation I have found myself in and need help weighing pros and cons! I graduated last May and am currently a hospitalist PA and have decided to start my pursuit into a career in dermatology (my initial interest that was reconfirmed after shadowing recently). I have joined SDPA, shadowed, have plans to attend a conference in November, and reached out to local pharm reps that unfortunately resulted with no responses from prospective offices. I applied to many derm jobs located almost everywhere with no response as well so I ended up sending inquiries in the "contact us" boxes of every derm office located in the area I wanted to end up in. This leads me to my current situation: I had a physician contact me after sending my email into their contact us box who was actually hiring (the job isn't posted anywhere online that I can find) and had a phone interview with them. I then was offered to come shadow the office for an afternoon and get a better feel for the position/learn more about the office. I thoroughly enjoyed my time there and following my shadowing, I then had another meeting with the physician who owns the practice (the same physician my phone interview was with) to talk more about what the position would entail. This is a relatively new practice that just moved to a new updated location (~5 y/o practice) and she prefers to train someone without derm experience (good for me!). She wants someone long-term since she will be training so she offered for me to come back for a "two week rotation" where I would shadow for another two weeks so that I can ensure I am actually interested before she potentially offers a position. This leads me to pros and cons list: Pros: -She offered both training in medical derm and cosmetics with the choice of which I would want to do more or less (she made the comment that whatever is legal for PA's to do in office, she would be open to teaching me) -PTO/401k with match -Her current APP has been with her all 5 years (they worked together prior to her opening the office and she followed her to work for her) -My location and specialty of choice -She's very kind and can tell that she would be a great teacher Cons: -She currently does not offer any health insurance (she did mention that she expects she will offer this within a year since the practice is doing well but can't guarantee anything currently) -5 year commitment (not a huge issue since I want this location but makes me a little concerned) -Salary was discussed as "range of $80,000-$140,000 depending of various factors" ..she did not get into specifics of salary or if any productivity bonus/% of collections would be offered from cosmetics (although she mentioned that cosmetics offsets her Medicaid patients so I am not sure if she would include this) I guess I am just looking to see if the no health insurance/5 year commitment sounds like a huge red flag especially with the chance that I most likely will be taking a pay cut and want to have some opinions before I go shadow for two weeks (on my week off since I work 7 on 7 off). She also didn't offer me the position formally yet and mentioned that she has been talking with other PA's (she plans to hire 1 or 2) so I would hate to go through all of the shadowing just to not even get an offer. I am leaning towards doing the shadowing and kind of expecting an offer which at that point, would ask about productivity/% of collections, but she sounded like she would not budge on the 5 year commitment. It is my dream specialty and dream location so should I accept the possibility of a potential huge pay cut for this or should I run the other way and keep looking? Any help or insight would be greatly appreciated!! (I also forgot to ask about malpractice insurance but will definitely bring this up if I decide to go through with the shadowing) Quote Link to comment Share on other sites More sharing options...
cabinsnow Posted July 27, 2021 Share Posted July 27, 2021 Expecting to be offered health insurance and actually being offered health insurance in a year are very different. Personally, I wouldn't take a job without health insurance even if just for a year. I wouldn't dwell on the five year commitment unless there's some non-compete contract stating such. Quote Link to comment Share on other sites More sharing options...
sas5814 Posted July 27, 2021 Share Posted July 27, 2021 Coin toss. You would be taking a chance on a new start up. That carries some risk but offers some possibilities too. You can negotiate almost anything and, in this case, if you were to jump in I'd want a "hard start" on health insurance and an opportunity to grown my earning as the practice grows and your skills improve. salary and RVUs or some such mix. The more you generate for the practice the more you earn. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 27, 2021 Moderator Share Posted July 27, 2021 that is crap 5 year contract nope no health insurance nope offer a one year contract for 100k with health insurance. If no health insurance needs to be at 110k so you can buy your own she has realized the money making potential of PA - derm doc costs $300k+, derm PA (well that 80k is insulting) and can generate similar income in a 1-2 time - so for the 2-5 years of a contract she is paying you 1/3 of a doc and generating almost as much revenue - resulting in HUGE income for her. If she wants a "partner" then she needs to be competitive 1 1 Quote Link to comment Share on other sites More sharing options...
CAAdmission Posted July 27, 2021 Share Posted July 27, 2021 11 hours ago, physassistww said: Salary was discussed as "range of $80,000-$140,000 depending of various factors" That's pretty loose. Quote Link to comment Share on other sites More sharing options...
trazodone Posted July 28, 2021 Share Posted July 28, 2021 A salary "Range" for a job being that large is a red flag and shows the employer has no idea what to pay you. You could use that to your advantage or you could be drastically underpaid if things do not go your way. a 5 year contract is insane and I would never sign on. Things change and if they change quickly you are in for a rough time. Ask me how I know that? 1 Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 28, 2021 Administrator Share Posted July 28, 2021 What is the physician looking for in a 5 year contract? It's always good to put yourself in the other party's shoes. - Guaranteed ROI for the training invested in you. I'd say this is the big one. I doubt anyone who is making such a big deal out of the health insurance bit knows how much individual health insurance costs an employer--it's pretty insane, and sorry, Ventana, I don't think $10k/year remotely covers good traditional insurance. I pay over 6k/year for faith based cost sharing and there are a LOT of limitations on what's covered with that. If you want to make this work, I'd be willing to come back with a counteroffer: - total compensation package rather than salary, so that you can agree to pay for insurance or not from pre-tax dollars. There may be some IRS limitations on how flexible that can be, but it's stupid to get a higher salary and have to buy insurance on the open market. - Compensation based on RVUs, not salary, and no PTO. That is, you work more, you get paid more. This places MUCH of the risk (e.g., get sick? Lose money) back in your court. However, it should also make sure that you're a net win for the doc's bottom line no matter what, BUT that your income will scale up for you automagically over time as you get better and more efficient. - I'd offer a scaled noncompete for derm in a reasonable radius equal to 50% of time since hire to a maximum of employment+noncompete of 60 months. That is, after 18 months in, you'd have a noncompete for months 19-27. But when you got to 34 months, the noncompete would cap out at 60 months total, and each month after that the noncompete shrinks as and if you continue to work there. Of course, you need reasonable safeguards in there... Outside the box thinking. Let me know if any of that seems useful. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 29, 2021 Moderator Share Posted July 29, 2021 4 hours ago, rev ronin said: What is the physician looking for in a 5 year contract? It's always good to put yourself in the other party's shoes. - Guaranteed ROI for the training invested in you. I'd say this is the big one. I doubt anyone who is making such a big deal out of the health insurance bit knows how much individual health insurance costs an employer--it's pretty insane, and sorry, Ventana, I don't think $10k/year remotely covers good traditional insurance. I pay over 6k/year for faith based cost sharing and there are a LOT of limitations on what's covered with that. Unfortunately I know all to well what health ins cost - $1545 a month for my family, best single rate (not high ded plan) is just under $800/m here - so 10K is the price of 100% single. Most employers seem to be shifting more and more cost the employee now. Interviewed with one up and coming firm (UC) and the cost share for individual was 50% and for family was close to 80% (they pay the 50% of individual rate and the rest is up to you - seems the prefer single PA with out family) 4 hours ago, rev ronin said: If you want to make this work, I'd be willing to come back with a counteroffer: - total compensation package rather than salary, so that you can agree to pay for insurance or not from pre-tax dollars. There may be some IRS limitations on how flexible that can be, but it's stupid to get a higher salary and have to buy insurance on the open market. If they raise your salary enough to cover the true cost of after tax $$ towards health insurance it works - also having your own company you can expense the insurance 4 hours ago, rev ronin said: - Compensation based on RVUs, not salary, and no PTO. That is, you work more, you get paid more. This places MUCH of the risk (e.g., get sick? Lose money) back in your court. However, it should also make sure that you're a net win for the doc's bottom line no matter what, BUT that your income will scale up for you automagically over time as you get better and more efficient. - I'd offer a scaled noncompete for derm in a reasonable radius equal to 50% of time since hire to a maximum of employment+noncompete of 60 months. That is, after 18 months in, you'd have a noncompete for months 19-27. But when you got to 34 months, the noncompete would cap out at 60 months total, and each month after that the noncompete shrinks as and if you continue to work there. Of course, you need reasonable safeguards in there... Outside the box thinking. Let me know if any of that seems useful. Non-competes - mostly 12m and maybe 10-15 miles - outside of that the courts/case law has said are unreasonable deterrents to the individual gaining employment. But that would take time and a legal challenge($$$). So pick a counter point like 12 months and a 15 mile (as the crow flies-straight line on a map) radius (that is bigger then you think) and present that. I would never go out to 60months. Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/27/2021 at 2:06 AM, cabinsnow said: Expecting to be offered health insurance and actually being offered health insurance in a year are very different. Personally, I wouldn't take a job without health insurance even if just for a year. I wouldn't dwell on the five year commitment unless there's some non-compete contract stating such. This is definitely why it's weighing heavy! Is health insurance a HUGE need for me at this point in my mid-20's? No, but 5 years is a long commitment and while we aren't rushing to have children right away, this could end up being a very very big issue if we change our minds. I decided to go through with the shadowing and try to get an offer in writing so I can try to start negotiations and see how much she will budge. Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/27/2021 at 8:53 AM, sas5814 said: Coin toss. You would be taking a chance on a new start up. That carries some risk but offers some possibilities too. You can negotiate almost anything and, in this case, if you were to jump in I'd want a "hard start" on health insurance and an opportunity to grown my earning as the practice grows and your skills improve. salary and RVUs or some such mix. The more you generate for the practice the more you earn. I am definitely going to be fighting for a percentage of collections if she offers me a position especially since she said her offer would include the opportunity to decide where I would want to focus (medical derm vs cosmetics) which could end up being full-time cosmetics once I build up the clientele. Even though she mentioned she uses the income from cosmetic patients to offset the medicaid patients (only she does cosmetics, her NP only does medical derm), I also don't want to be her cash cow. It's gonna be hard to turn down an offer since an opportunity for a no-experience derm position doesn't come by often, so I hope she will budge some so it will make my decision easy! Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/27/2021 at 12:58 PM, CAAdmission said: That's pretty loose. Agreed. I decided to go through with the shadowing and see if I get an offer and if I do, I will definitely keep you all updated with the specs. While I don't have direct derm experience, I did rotate in plastics clinical year and have been working in hospital medicine for almost a year so not a complete new grad and expect the offer to reflect that. Though I'm worried it may be difficult to negotiate since the first 6 months will be "training" and it's often recommended to accept the low salaries for derm jobs since it's so hard to break into. Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/27/2021 at 10:46 AM, ventana said: that is crap 5 year contract nope no health insurance nope offer a one year contract for 100k with health insurance. If no health insurance needs to be at 110k so you can buy your own she has realized the money making potential of PA - derm doc costs $300k+, derm PA (well that 80k is insulting) and can generate similar income in a 1-2 time - so for the 2-5 years of a contract she is paying you 1/3 of a doc and generating almost as much revenue - resulting in HUGE income for her. If she wants a "partner" then she needs to be competitive Her reasoning for the 5 year commitment is that she doesn't want to waste time training someone for them to just get 1-2 years experience and leave. I can understand this but 5 years is a LONG time. If she gives an offer which I am honestly fully expecting (hope I didn't just jinx myself), then I am going to try to work in an automatic yearly increase in salary with % collections (I have to do more research on this kind of model.) I would honestly accept a slight (and I mean slight) pay cut compared to what I'm making now since derm is hard to get into, but I refuse to make $80,000 a year with no % of collections for the next 5 years. I understand that my first year I won't be very profitable, but year 1 and year 5 would be DRAMATICALLY different in terms of how much income I am generating for them. I am just really hoping her intentions are true and she's not just looking for someone desperate (me) to boost her practice income for the next 5 years. Unfortunately I know if I don't take it, someone will. Thanks for your input. Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/28/2021 at 11:57 AM, trazodone said: A salary "Range" for a job being that large is a red flag and shows the employer has no idea what to pay you. You could use that to your advantage or you could be drastically underpaid if things do not go your way. a 5 year contract is insane and I would never sign on. Things change and if they change quickly you are in for a rough time. Ask me how I know that? She mentioned the range in casual conversation and then casually dropped that her NP does "very well." I am hoping she was just giving an example and would take my relative experience into consideration with an offer. I agree that the 5 years is excessive. If she gives an offer in writing with this, I'll be interested to review the conditions and hopefully can negotiate it down to 3 which sounds like something I'd be a little more comfortable with. If you're holding back a story, I'm all ears! Quote Link to comment Share on other sites More sharing options...
physassistww Posted July 30, 2021 Author Share Posted July 30, 2021 On 7/28/2021 at 3:35 PM, rev ronin said: What is the physician looking for in a 5 year contract? It's always good to put yourself in the other party's shoes. - Guaranteed ROI for the training invested in you. I'd say this is the big one. I doubt anyone who is making such a big deal out of the health insurance bit knows how much individual health insurance costs an employer--it's pretty insane, and sorry, Ventana, I don't think $10k/year remotely covers good traditional insurance. I pay over 6k/year for faith based cost sharing and there are a LOT of limitations on what's covered with that. If you want to make this work, I'd be willing to come back with a counteroffer: - total compensation package rather than salary, so that you can agree to pay for insurance or not from pre-tax dollars. There may be some IRS limitations on how flexible that can be, but it's stupid to get a higher salary and have to buy insurance on the open market. - Compensation based on RVUs, not salary, and no PTO. That is, you work more, you get paid more. This places MUCH of the risk (e.g., get sick? Lose money) back in your court. However, it should also make sure that you're a net win for the doc's bottom line no matter what, BUT that your income will scale up for you automagically over time as you get better and more efficient. - I'd offer a scaled noncompete for derm in a reasonable radius equal to 50% of time since hire to a maximum of employment+noncompete of 60 months. That is, after 18 months in, you'd have a noncompete for months 19-27. But when you got to 34 months, the noncompete would cap out at 60 months total, and each month after that the noncompete shrinks as and if you continue to work there. Of course, you need reasonable safeguards in there... Outside the box thinking. Let me know if any of that seems useful. I agree with your reasoning behind the 5 year contract. I do understand that she doesn't want to spend her time and energy training someone for half a year for them just to leave after 1-2 years. I just hope she understands that the remainder of the contract has to make me WANT to sign on for 5 years. I am also not the best at negotiation (or confrontation in general) so am hoping that she's expecting some counter negotiations to make my life a little easier. I am not sure what her current (and only APP) NP's package includes but she's been there for 5 years since the opening of the practice, so she must be doing something right, right?? I'm going to be completely honest (as a mid-20 year old and only a little over 1 year since PA school graduation) that I know close to nothing about noncompetes and the in's and out's of health insurance options. So THANK YOU for the insight. I went straight from my parents insurance to a structured large facility plan so was not forced to explore the details. I will do some more research and digging with this information and hopefully make up an expected an offer with alternatives you provided. You were very helpful and have given me a lot to consider, thank you!! Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 31, 2021 Administrator Share Posted July 31, 2021 You're not alone--with the programs selecting younger students with higher academic achievement and less real-world experience, your peers are in the same boat. - Understand that most HR scumb... err, professionals are not interested in negotiating, but in getting the most work out of you for the least. Their professional charter is to cheat providers and protect the organization, so your only hope of actually crafting a nice worthwhile package is negotiating with a physician proprietor directly. - But even then, most people, PAs and MDs, absolutely suck at negotiation: they either get offended too easily, or accept a "and that's my final offer" as if that statement was ever more than occasionally true. We don't haggle at the market anymore! Heck, how many undergraduates ever had to read something like Fisher & Ury's "Getting to Yes"? At any rate, best wishes on whatever happens next. 1 Quote Link to comment Share on other sites More sharing options...
virtuous woman Posted August 24, 2021 Share Posted August 24, 2021 How did the shadowing go? Quote Link to comment Share on other sites More sharing options...
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