Justin: 00:23 Welcome to this episode of The Anesthesia Success podcast. I’m your host Justin Harvey. Our guest for this episode is Dr Jay Grider. Jay is the associate chief medical officer for UK healthcare ambulatory services and is the medical director for UK healthcare pain services. Jay has lectured nationally and internationally on topics related to neuro-modulation, interventional techniques and opioid pharmacology. I had the pleasure of meeting Jay in San Antonio a couple of weeks ago and really benefited from his perspectives on practice management and contract negotiations for physicians, specifically contracts for early career pain doctors. Jay is here today to share a bit more about important contract considerations for physicians in this space. Jay, thanks for joining us.
Dr. Grider: 01:27 It’s good to be here.
Justin: 01:28 Just so our listeners can get a bit of background on your experience, why don’t you share with us a little bit about your career, which includes a PhD as well as an MBA and I love to hear how those experiences have shaped your trajectory as a physician and a leader.
Dr. Grider: 01:40 Sure. With regards to the topic at hand, my real experience became whenever I took over the training of our fellows at the University of Kentucky and we were going through a transition ourselves where we were moving away from an academic business model to one that was a little bit more financially viable and I’ll just kind of leave it at that. Well, to be frank, because a lot of academic pain programs are not financially viable and that’s, that’s a little shocking to me to, to not be financially viable, running a pain programs like little, like not being able to be financially viable, running a money printing press. But that’s beside the point. So as we became more business savvy, I began to realize that my fellows were going out and were transitioning from one practice style into something else.
Dr. Grider: 02:34 And a lot of times it was like listening to a plant describe the motives of a mammal whenever they would go out into, into a different environment. And it was like, what are these people talking about? And on the receiving end I heard that a lot of our private practitioners would say, you know, I get a fellow from an academic program and I just figured that it’s going to take me two years to get them up to speed on just how to function in the real world. And so I thought there a way to bridge that gap a little better from a training standpoint and from a business standpoint. And since we were changing the way we functioned anyway, fellows started gravitating to us because we were able to offer them as close to a real world experiences they could, could get now other, other academic programs or are doing similar things. We’re not the only ones, but we’re pretty intentional in talking about why we’re doing what we’re doing.
Justin: 03:24 Okay . And can you elaborate a little bit about how your pain program has evolved and maybe it’s different from a traditional academic program?
Dr. Grider: 03:30 You know, as with all things, my basic philosophy is if you begin with the end in mind, you can construct something very intentionally and if the ending that you want our patients to have great access and patients do have a great experience and as much throughput as possible and what the doc wants is to be busy and functionally active and to provide as much service as they can without getting ahead of themselves from a, from a business standpoint or standing around doing nothing. And they want to create a good income. Once you get all of these things aligned, sometimes you get situation set up where these are at at 90 degree angles and they’re working at cross purposes, but whatever you get all of these things aligned. Then your business model and your clinical model function seamlessly because they’re all trying to accomplish the same goal.
Dr. Grider: 04:24 And when you add in the academic piece with the academic model supports the business model and the clinical model, then everything is moving in a direction that is ideal. And so you hear a lot of things in the current environment where physicians talk about their needs and sometimes they’re at odds with the needs of the patient. And sometimes patients talk about, I feel like I was just in the mill, I was being cattle card through a system and, and that’s at odds with their needs and their desires. So how do you balance all of that to get the best outcome? And that’s what, that’s what we tried to do. So the clinical was backing up the, the business model. And if those two things are divorced, you’ve got a problem right at the beginning and I and I can talk more in depth about that or just kind of leave that ambiguous if you want me to.
Justin: 05:10 Sure. Yeah. And it seems like the pain sub specialty specifically, there’s more of a tendency to maybe be have a jarring transition because so much of it is on the private practice side as an attending that’s perhaps a, you a fellows coming through that track or maybe uniquely challenged to be able to negotiate that transition. Would you say,
Dr. Grider: 05:29 well, and here’s the reason why, because most fellows come from an anesthesia background. So for years you’ve been taught, you’ve been told where to go, what room to go to, what to do in anesthesia practice sort of functions. That way. There’s somebody centrally sort of coordinating the workforce and go do this, go do that. We need you in this room. We need you in that room. As many people go into pain because they would like to have a more independent view of their life than that. So when they go into pain, it’s hard to get out of that mindset and then they enter a practice when you’re later. That is probably one of the most entrepreneurial field out there and so it’s, it’s a culture shock and so that’s the real transition is going from almost a year mindless being told where to go into a one year transition in an academic place into usually a well oiled entrepreneurial machine.
Justin: 06:21 Yeah. What types of things do you guys do with your program to be able to help fellows make that transition? Uh, and this essentially like a one year, not only clinical training, but also probably business and economics and understanding the behind the scenes math of how a pain practice works.
Dr. Grider: 06:37 Yep. So we have a pretty intentional process where again, training isn’t done in a haphazard fashion. It has been done in a haphazard fashion anywhere else. Training is done well, I mean from a clinical monitoring standpoint, what I’m talking about is a professional growth track. And in that professional growth track, what we want to emphasize is at the very beginning, it’s a I do you watch, and that stage lasts very, very, very, very short period of time and we immediately transitioned pretty quickly into a, I do you help. Then we try to transition as quickly as possible from an do you help into a you do. I help. Then as quickly as we can, we want people to get to an independent place where it’s an idea you do, I’m assisting or watching and that grows professional competence very quickly. So for instance, if you know that you’re going to be going out and having to see between 20 and 30 patients in a day minimum in order to meet your overhead needs in your income needs, then working at a clip of eight to 12 is not what you need to do.
Dr. Grider: 07:50 It’s not training you for what you’re going to need to do. You’re going to have to get up to speed and you’re going to be doing it in an environment where you’re actually not only having to get up to speed, but you’re having to perform. And so no one would ever put a concert pianist onstage and say, here’s the music I want you to play. Play it that way. That would just never happen. No quarterback would ever go on a field and the coach say, here’s a whole series of plays that we’ve designed. Let’s, let’s see how this goes. That just wouldn’t happen. So I want them to. I want them to have at least practiced what they will be doing in a real world at some point. So we grow gradually. Our goal isn’t for them to be a production machine on day one, but by day 240, we need to be thinking, how are we going to be transitioning you into what’s a real world setting?
Dr. Grider: 08:36 So at first we want that. We want the academic given take and we’re working around you to keep that going. But eventually we would like for you to be deriving the machine. You’re turning the flywheel so that you know what it’s like to see 25, 30 patients and be responsible for that with us in the background. Ensuring that the care plans and transitions and all those things are, are, are, are appropriate now by no means are we saying you’re on your own and, and we are divorced from the care. It’s you are driving the machine, you’re in the room with the patient, you’re seeing what it’s like to have to be in two places at once and managed some of those issues, you know. So that’s kind of the thought.
Justin: 09:18 Okay. So for a physician in this place who is about to transition, maybe it takes somebody who’s who hasn’t come through your program, but it’s still looking to try to understand what type of mindset adjustment or you know even understanding professionally how the operation from the academic private practice side is going to evolve. If you had to give it like a three or five minute dump on somebody in this position, what are the important things to think about or consider that maybe they haven’t been exposed to before?
Dr. Grider: 09:46 So the real thing is how do you get maximum value add with patients in the right amount of time. And so anybody who’s talked about any sort of critical relationship, there are basically two things that you have to offer. You can either offer quantity or you can offer quality and quantity is the easiest thing to provide somebody. Somebody will soak up 45 minutes or somebody will soak up 25 minutes and so you give them 25 minutes, but oftentimes you’re doing that, but the patient still leaves and gives you a slam on the patient satisfaction score because you’re not directing the care. There is a way to provide timely quality interaction by getting at what the patient truly wants and patient truly needs. And so the quicker you can ascertain that, the better you are getting the quality rather than quantity. And so that’s the real frustration is in the academic programs, sometimes the difficult patients or the hard complex patients, they get treated with quantity of time and you’re thinking to yourself as a, as a fellow, I’ll never be able to spend this much time.
Dr. Grider: 11:00 So you’re not even practicing the skill that you need. How do you give the patient high value, high quality time, and sometimes that causes you to have to rethink your clinical model because sometimes what they need is is care, but not always intensively from the physician, but there’s a way to provide care within your clinical paradigm that doesn’t necessarily have to be provided by the clinician itself and that’s setting up care pathways with nurses, with even with your staff that rooms patients to the visit really begins from the moment they walk up to the window, how do you get the maximum value and make them feel like they’ve been heard and their needs have been addressed.
Justin: 11:42 Yeah, that makes a lot of sense. I’m glad you brought that up. The care model consideration and for somebody who’s transitioning to a new entity for employment, you know, looking at different care models that may exist, whether it’s a physician practice or a team based model, can you maybe compare and contrast those and give some things to think about for somebody who is perhaps looking at a job offer with a physician only versus a care team?
Dr. Grider: 12:03 Well, whole care team models don’t usually exist. That’s the first thing, so this, this idea of interdisciplinary pain programs, it is a bit of a misnomer. In reality, if we were treating pain effectively, it would be done with, you know, large amounts of social work in rehab for the true chronic pain issues. So the real issue is you have three separate groups of patients mixed into your population. You have people with musculoskeletal issues that when you solve them or whenever you address them, they go away and so somebody comes in and their shoulder hurts, their neck hurts, their back, her to do something for them and they go away for a period of three to five months and they don’t really need anything from you and and and what they want is quick in and out access. So you have to understand that person.
Dr. Grider: 12:56 Then you have the person with a, with a next level up complexity who they maybe have a radicular pain in their leg after surgery or their arm or something along those lines and you’re able to do something for them. They also have a more complex need, but they also don’t want to interact with your health system is much and then you have about a third of the patients, the final third that basically need intensive resources and so we have one clinical model that we address all three width and so the first group gets frustrated because they don’t have the in and out access enough and the final group gets frustrated because they need something more than a 15 minute interview with a physician or an or an injection and so and that’s where things fall down. Most practices, those are very resource intense sorts of things and that’s where we fall down in the pain community. If you can solve the first two well and be able to recognize that that chronic population that needs something else, that’s the first step is in in recognizing that population and starting to at least think about how you’re going to manage it because most people don’t manage it. They just dread seeing that person show up on their schedule because they don’t have anything really. They know it’s going to be a hard, long conversation that somebody is going to leave frustrated every time, but they don’t have anything to offer them.
Justin: 14:16 One practices manage those types of patients effectively. What do they do?
Dr. Grider: 14:20 So on some level those people really ultimately want a connection and so little small touches that let them know that you care deep down they know that you’re not going to solve their issue. They just want to know that you can at least empathize with them. And so a model that’s really efficient at getting people in and out quickly isn’t necessarily a high touch high care model. And so you have to be able to, to be able to deliver to different at the same time. And uh, and empathy can be delivered quickly. That that’s really the thing is most, most of the patients in the third category don’t have a treatment option that’s going to dramatically change their situation. But you know, the old television show cheers, sort of the idea, you know, you just want to kind of go where everybody knows your name and
Dr. Grider: 15:14 you know that that can sometimes have a value.
Justin: 15:17 Sure. Cool. I want to pivot a little bit and talk about transitions and employment that are going to impact somebody’s career and economic situation for years to come and helping doctors discern the differences between two different types of employers. So if we, just to kind of build a couple straw men here to consider if we’re looking at a smaller one or two or three physician pain practice versus maybe a larger pain practice either attached to a hospital or, or a bigger private practice. Can you maybe compare and contrast some environmental factors like you know, what is the clinical practice going to look like in these settings and economically kind of how compensation might be structured in each of those.
Dr. Grider: 15:56 Sure. So starting with the most basic element, the single proprietor, who has gone out on his or her own and they’ve started their own practice and they, they took all the financial risk and they’re working out of their office and their practices growing and they would like to add somebody to. The most important thing for a fellow or even a somebody who’s been working in a hospital setting to understand is that that person has all the chips in it. You talk about skin in the game. Nobody has more skin in the game than that person and so there is a. There is a nervousness about adding someone to that, that situation and the person has to understand that this is the ultimate small business. So whenever you join that, until you are productive, that person is essentially taking food off of their own table to have you there and so the offers are not as lucrative.
Dr. Grider: 16:55 There is a sense that you pick up that things are being held back, that you’re not getting the whole story and that’s because there is a. there’s a nervousness to that. Then the people don’t intend for it to be that way, but they actually create relationships that cannot sustain longterm because all the power rests in one place and and none of the power rests in the other and it’s an inequity that can just never be bypassed and so it takes a really skillful person to be able to create something and then create a business climate where they can grow it and enhance it and those are skills that just brightened frankly aren’t taught in medical school. So the first question to ask is really, you know, how many people have you brought in and you’ll often hear in the warning sign places, but I had a guy a couple of years ago and that one didn’t work out, you know, and, and that, you know, those are the situations that are, that are difficult.
Dr. Grider: 17:48 My general rule of thumb is if it’s a single person, you have to make sure that that person really has genuine motives in bringing that, bringing on a partner. If there’s two, I jokingly say that can still be a danger zone because that can be two to golfing buddies from the anesthesia group who decided they were going to go out and start their own practice and they’d been together for a long time and they’ve worked it out, but when they add you, and that’s a different animal, so it’s really those two are really one person. Once the group gets the three, they have usually figure it out, the dynamics of how to interact with each other without killing each other and it goes pretty well. Got It. So I was just looking at a at a contract with one of my fellows last night at a place where they have seven divisions on board and you can tell by the way the offer is written, even though there’s some ways to hide traps and quicksand, they have a pretty well oiled way of bringing on somebody and a pretty clear cut way of managing the finances.
Dr. Grider: 18:49 And with seven people you have to assume that seven people aren’t going to let you screw them and just sit there and take it to that. There has to be, it has to be some physician equity that is a value. Then you have to figure out if you’re okay with the culture,
Justin: 19:04 so if you find one of these one physician or to physician practices and you really jive with, you know the personality in the ethos of the practice and you are inclined to move forward with it, you know, is there anything that a fellow in that position can do to make sure that they get a fair deal? Because obviously you’re not saying categorically exclude the smaller brands.
Dr. Grider: 19:23 No, no, of course not. The biggest reason is physicians don’t sink in a strategic business sense on why they are expanding their operation because for the most part, if I own a practice and I’m as busy as I can be maximized my income, what really is there in it for me to grow other than there is demand there, but you’re really growing something for another person and you don’t get a lot out of it. With the exception of you can begin to spread overhead around and that that has value, but many a person is looked around and said, I’d rather just eat the overhead then deal with that guy and that’s where the problem comes in is they don’t know why they’re expanding, so it if you’re seeing 40 people a day and you are as busy as you can be and you’re making all the income you can make and you are, your widgets are coming down the line as fast as you can manage them, adding somebody.
Dr. Grider: 20:23 Does it change your process? It does increase your complexity. So the first step is asking really intuitive questions. Why are you wanting to expand and hearing what they say about that? If there’s a poorly thought out of, well, you know, there’s just a whole lot of demand out there. I mean, I’ve seen practices where I’m booked out eight weeks and so I need to bring somebody in. They brought somebody in and that eight week backlog went away, but there really wasn’t enough work there for two people to do. He just had a backlog where she just had a backlog and they didn’t perceive the real need. And then you have a situation that’s the worst possible thing where two people are competing over scarce resources. I call that thunderdome. That’s the old movie from Mad Max where the line was two men enter one man leaves and uh, you know who that’s going to be if you’re the second person in.
Justin: 21:18 yeah, and you mentioned this other dynamic that I want to bring up. Uh, you know, in one of these smaller practices when two physicians, two fellows perhaps are hired at the same time and you mentioned that’s a danger. Can you expand on that a little bit?
Dr. Grider: 21:29 Sure. Two people who come in straight out of a fellowship have very different practice styles. And so for instance, I’ve seen it happen all the time and like a large orthopedic surgeon, multi-specialty group will say, we have enough volume for two people. We want to start off. What that usually means is we interviewed too, and we couldn’t figure out which one we wanted. So we thought we’d bring in because by Golly we’re big and we
Dr. Grider: 21:53 but they bring two people in. One was trained at program x where every patient gets deep sedation for their procedures and they’re done which turns over slowly and the other was done in an office setting, you know, where they don’t get any sedation and and they do 12 procedures in a day and they’re doing other things at the same time and both arrived simultaneously. And as you always do, whenever physicians start bellyaching about something, the organization will try to accommodate both rather than setting up a standard work. And so you have one person who’s all their patients are getting sedation and so they’re holding up the PACU space for 45 minutes and then you give four milligrams of [inaudible] to the 72 year old and she’s asleep over there in the corner until noon and you can’t turn that bed over. And the other guy who doesn’t give any sedation is going, dude, what are you doing? You are absolutely killing my throughput in my productivity. So a lot of times these differences in variation in practice style, until you determine how the practice is going to work and somebody is added into that standard workflow, it it’s difficult to create two standard workflow simultaneously without somebody understanding that you have two competing workflows in business, you would. You would never allow to different ways of doing the same job to be done in parallel. You just wouldn’t. But in medicine we do it all the time.
Justin: 23:22 makes sense and so on. I think you gave us a good snapshot sort of what the smaller practice considerations are. If we. What if we look at a bigger pain group, how do those dynamics change a little bit as far as prospective employment.
Dr. Grider: 23:34 So whenever you enter into a larger group, you are entering a culture, you are entering a way of doing things and you’re entering a a business and a clinical philosophy and you have to understand that there is room for some variation, but not a lot. For instance, if the business model is built on, we don’t say no to opiate management and you strongly are of the belief that opiates should be eliminated for most patients and minimized in the majority. You got a philosophical issue right there. You enter into a program where you intend to do intrathecal therapy and the practice does it want to do that because on that, since you’re covering each other’s liability, but you know that intrathecal therapy, it is a valuable treatment option through right there. There’s a, there’s an issue there, even groups that don’t want to manage spinal cord stimulation, so if you want to be an implanter, but you’ve got two other physicians there who don’t implant, uh, they don’t want to cover your, your issues or your problems whenever you’re out of town. So even really subtle things are really a big deal. They will be surprised as they go out. Even just the way that you do procedures, you think that sterile technique, everyone agrees. Sterile technique is important. Sometimes sterile technique is I rolled my shirt sleeves up whenever I do the procedure to I put on a gown and gloves whenever I do x, Y, and z. So something as simple as, Oh yes, we strictly adhere to to sterile technique can be open to wide, wider degrees of interpretation than the fellow would ever anticipate.
Justin: 25:12 Are there any ways that you’d recommend a fellow being able to determine these clinical philosophy differences potentially at, you know, during the vetting process because that sounds like some things that you might not be able to determine until you’ve been, you know, practicing somewhere for a little while.
Dr. Grider: 25:29 Getting your first job out of fellowship is, is if you were told, go find someone to marry on July one and you know, just that’s your goal. You would go out and you would look for someone and you make the best decision you could. Knowing that there was a time crunch, but that’s not the way we ever do things.
Dr. Grider: 25:50 Take pressure off of yourself with your first job. Don’t necessarily think of your first job, you know, till death. Do you part it? It’s, it’s still, you have your Popeye moment, you know, and every Popeye cartoon, there’s this, there’s this moment where Papa says, you know, I’ve had all I can stands and I can’t stands no more. So whenever you, whenever you’re ready to have your Popeye moment, that’s whenever you know it’s time to move on. But I would anticipate that the likelihood is that that will occur. So you don’t go into a negative, you just go into it with less pressure on yourself that, that first choice has to be the optimal choice.
Justin: 26:25 Yeah, it makes sense. And I think there’s probably just also an objective observation and one’s own part that the informational asymmetry between prospective employee and employer or a prospective partner and you know, the practice partners is at its greatest, uh, at the beginning of your career and you’re more likely to probably make a decision that 10 years the line you can, you know, in hindsight you might not have been optimal. So I think that makes a lot of sense.
Dr. Grider: 26:48 But the issue is just real quickly is you also don’t want to burn everything down. So if you’ve got to live in a geographic area and you go in and and you’ve entered a practice that has a 25 mile, you know, a restrictive covenant, then you, you’ve got to think long and hard about that. You’re like, let’s say for instance, because of a family situation or x, Y, or z, you got to live in the geographic area. You can get yourself into, into real bonds where you’re stuck in a place a longer than you’ve been to and, and another way that people get themselves into real bonds is just with their own stupidity in their personal spending habits. So let’s say your role into, into a medium sized city and you’re by a gigantic house and you can’t move it, and so you’re stuck there because you, you can’t get away from this Albatross that you’ve surrounded yourself with. I would, I would be very wise with your first move out. I would enter that with caution.
Justin: 27:46 Yeah, yeah, absolutely. I think there’s that period of time, you know, in the early practice years when if you can resist for a little bit, obviously doctors have delayed gratification for a long time in med school and training and all that, but if you can do it for a little bit longer, you can really lay a solid financial foundation for yourself and family.
Dr. Grider: 28:02 Yeah, I’ve actually got a whole lecture on that. It’s a different topic in and of itself, how to, how to set yourself up in the first, the first 15 months after practice.
Justin: 28:11 Oh, great. Well I’d love to hear that at some point perhaps in the future. So as we continue here, I want to talk a little bit about compensation because you know, when you’re a fellow, you’ve every year through training you just get a number. It’s a flat salary number between 50 and 70 k probably or maybe a little more and you’ve never had to think about the different components of your compensation. You’ve never had to do a math problem to figure out how much money you’re going to make. You just make the money that you’re promised. And then obviously when you, when you take this role as an attending, all of a sudden you’re doing math, you’re trying to understand the different scenarios in which how much you’re gonna get paid and there can be a six figure implication to that math problem that you want to make sure you’re doing the math. Right? So in that context, can we talk a little bit about, you know, war values and understanding how our contract structured, when there’s a math component, if we’re looking at a base plus an RVU target or if there’s net collections involved, what are the important things to be aware of with regards to compensation that you have never had to deal with before as a physician?
Dr. Grider: 29:09 So first of all, uh, work RVU, all physicians are paid on an RVU basis whether you are in private practice or not. And not everyone appreciates that. And the reason why is because centers for Medicare services looks at work complexity based on an RVU system. So it’s the unit lists number that is applied to clinical work to give you a ratio of how complex it is. For example, if you’re doing a 15 minute office visit, that is a number of of basically one. If you’re doing a skull base surgery and neurosurgery, that takes 12 hours, that might be 65 work relative value units, meaning that they consider that skull base surgery to be 65 times more complex than that 15 minute office visit talking about blood pressure, so it’s a way of determining the complexity of clinical work and everything is based off of that.
Dr. Grider: 30:06 Even your cash payments in private practice is based off of a work RVU value. It’s just hospital systems use that as a way to track physician productivity because it. It’s a pretty reasonable measure, but the payment systems of all the insurance companies, the rating scales are created on work RVU basis, so if you’re working in a hospital based setting, they will create a work RVU platform whereby this is a base amount of work. Our values for for interventional pain programs using MGMA numbers in the last couple of years that’ll. That’ll be somewhere between 5,000 and 6,000. Typically I see it around $5,300 as a base salary or the base work RVU unit per a base amount of money. Usually they tied the 50th percentile and work are abused at the 50th percentile in pay, which is arranged between 3:50 and 4:20. So three fit between three slash 15 and four slash 24 work RVU range between 5,000 and $6,000.
Dr. Grider: 31:05 So what that means is whenever you see patients, whenever I see a followup patient that will generate about one point five work or abuse, whenever I do an epidural, that joy that generates about one point five work or abused, you add those numbers up through your day and throughout your week and throughout your year and whenever that number equals 5,500, you have met the baseline expectation for your salary, which was $375,000 from this institution. Now the incentive usually comes in on that 5501st work RVU They will pay you a dollar amount for that RVU over and above. That is typically between 45 and $75 with the median being about 64. So for that next work RVU 5,501. You got $64 that added into your ledger. That’s a way of accounting for your work over and above the baseline expectation for your salary and they will usually pay that out as a flat rate all the way up.
Dr. Grider: 32:07 Some institutions above a certain amount, say 12,500, we’ll start to cap it or will start to pay less and less so that they can prevent you from driving volume through in a way that limits quality. That’s pretty short sighted. It suggests that you’re too stupid to know how to manage both and they have to do it for you because there are some people that just would would continue to to cattle car people through a in a way. But if you’re. If you’re clinical model and your business are setup with the end result in mind, which is great patient care and patient satisfaction, that has provided efficiently and expediently in the best manner possible, you’ll think those things through. But that’s the way the salary system works in most hospital based settings or RVU based settings. His base salary is one component at a percentile tied to a work unit percentile.
Dr. Grider: 33:03 Then for every dollar or for every unit produced above that baseline that they pay a set dollar amount. So those are the three negotiating pieces, uh, the base salary tied to the work RVU number tied to a unit number for each piece above that. So when you’re negotiating, like for instance, if you come in wanting a high base salary, that makes people nervous because many a person is coming in asking for high base salary and never produced up to that amount and that’s just cost added. So a, a really a way to get someone’s attention that you have good intentions is to say I’m willing to take a lower base salary that has a lower baseline RVU target. And then everything above that is upside. That way if I don’t hit it, you’re, you’re not out. So you know, but that, that creates upside incentive for people. So that’s one way of doing that negotiation.
Justin: 33:58 Yeah, that’ll make sense. Jay. And as we’re winding things down here, I want to touch finally on what does it look like to be a sole practitioner and specifically if I’m a, an early career pain doc and I’m looking to start a practice on my own potentially from scratch or essentially from scratch. I want to examine some of the things to look out for. I met a gentleman and Ezra, Dr Matt Kaplan. I don’t know if you know Matt. He’s based out of Austin. He was telling me a story about him as an early career attending, wanting to start his own thing and this is something where I think I really personally resonate with a lot of people in the pain community because it’s very entrepreneurial as a specialty. And so he moved to Austin, didn’t live there from out of town, started from scratch, pounded the pavement to build the network, the referral base with other physicians, got set up with space and had to clear a number of business and regulatory as well as clinical hurdles in order to make that work and make something happen from nothing. So in the context of a physician coming to you and saying, Hey, I think I can do this. Maybe there a fellow or maybe they’ve there three or four years out of a, you know, in the practicing as an attending, what kind of advice would you give someone like that to try to enlighten them to what they might be up against?
Dr. Grider: 35:13 Here’s the thing I would say, and I, and I just had a discussion this morning about this is with regards to starting your own thing. I’ve known lots of really experienced physicians who thought that they understood the business of medicine and more specifically the visit of the pain management but didn’t know what they didn’t know. And because of that, they moved from rather salaries into a place where I’ve known people who because of not getting on insurance panels in a timely fashion or not knowing how to file claims as accurately as they thought they did, they thought they understood the process, but they didn’t really understand the nuts and bolts of it and it’s on them for the first time. One of my friends didn’t drop his first bill for almost 13 months. We hired a practice manager who he thought he told him, Oh, I’ve done this for, I know what to do and didn’t have a second problem.
Dr. Grider: 36:08 And ended up hiring a billing company and some of the air that it was sitting there was not retrievable at all. And so then that’s a worst case scenario in this person went from a almost a seven figure income to basically living off of savings, you know, while they were going to the school of hard knocks. And also once I got out on their own, realized, you know, what that income that the hospital was, was making. I can’t recover. It was only through the partnership that I had with the hospital that we did that well. There’s no way for me to do as well financially as I could with a hospital system that was swimming in the same direction I am. The fellow that I was speaking with this morning is is joining a large multi-specialty pain group. They have seven or eight positions and so they’ve figured out how to interact with each other in a in a reasonable way and and so his first negotiation was based salary.
Dr. Grider: 37:04 Should it be higher or should I go with upside? He wanted to have a higher guarantee because he wasn’t sure they were dealing with percentages of cash collections. What I cautioned him, what was, what I’ll. I’ll say that to anybody you know, listening to the podcast at some point, unless you’re running your own practice, you will wake up and you thought you were in private practice, but you are really no more than an employed physician. So the person who is truly out on their own is rare. You are in an employed situation almost virtually every, every time Walmart hires and employee. So that they can make profit, so any company is hiring you to make profit. They are not making. They’re not an altruistic setup, they’re not hiring you for your own personal benefit. If you benefit, that is okay, but they are hiring you to make a profit for the corporation and whenever it’s a small corporation with a single proprietor, whenever it’s Dr Jones Llc that you’re working for, the person who will be making the profit is that physician or that small group of physicians.
Dr. Grider: 38:20 So when they pull in with a Maserati next to you, you are funding that and at some point in the first three to five years you wake up and realize that so no matter where you go, you are creating margin for somebody for something. And so you have to figure out whether you’re okay with that. Because the first thing that happens is whenever people realized, heck, I’ve been funding your lifestyle, they get mad and I want them to understand there is no reason to get mad. You had some unrealistic vision of what you were doing to begin with. You thought somebody was running a nonprofit for you to benefit, so a nonprofit is having you work there so that they can generate extra margin to reinvest into their operations to continue to provide services that meet the mission of the nonprofit, whether that’s a hospital or a large multi specialty group.
Dr. Grider: 39:12 If it’s a small private group that you’ve joined. The nonprofit or the group that you are benefiting is the small group of owners. So whenever they say you get 30 percent of collections in your three, what they mean is we’re going to pay our overhead, our 45 to 50 percent overhead. Then the gap or the Delta between your 50 percent overhead and you’re 30 percent collections goes to us. You are paying us for the privilege of us dealing with the headaches. And so when you find that out, don’t get angry. You haven’t been screwed. Whether you’re working for a hospital or you’re working for a small private group, you are creating margin. They did not hire you for, for your own benevolent existence. And so that’s whenever people get in the huff and they start arguing over that 20 percent and they leave in a huff to go out and do it on their own, but what they realize is it’s not as easy.
Dr. Grider: 40:11 That guy or that Gal took years of learning, of failing, of figuring out 55 ways not to do it, to figure out how to do it, and so you are paying them a premium for that experience. And that’s the thing that I would say to anybody who was looking for employment. You think you’ve gone out into private practice to work with, with the multi-specialty group and you have not done something that is in your own best interest. You are still funding the best interest of another. It’s just you have to be okay with your take in that. No one, no one who works at Walmart gets mad because Walmart is a multibillion dollar corporation. The agreement you have signed is I will do what you’ve asked me to do for this amount of money and I’ll show up and do it to the best of my ability and Walmart worries about everything else so the doctor really has to understand that even when they’re in private practice, they are no more than an employee unless they go out and they start a small business, which are they lonely hard thing to do and virtually no one is doing that.
Dr. Grider: 41:14 They all see the large group and they dream of being the guy who owns clinics in 10 cities with 70 locations, and let me tell you, that all started with one person working pretty hard. What ended up happening is you’ll find that most of the guys who were running those large practices interestingly are still practicing four or five days a week, sometimes three days a week, so they haven’t generated enough income through that growth process to truly hit escape velocity. Like if you owned 10 McDonald’s and you are, your job is to manage those businesses. You’re not running the day to day operations of that business. You have passive income even when you’re gone. Most of those people are still pretty heavily clinically active in order to make the incomes that they want to make because there is margin in some of these things, but it takes a whole lot of that margin to keep things growing and expanding. That’s the piece that I would say to the, to the fellows as they go out, is that’s where things go south in your three to five, whenever you wake up and you go, I’m getting screwed. You’re not getting screwed. It’s just. Unless it’s yours, you are creating margin for someone else to distribute as they see fit. That’s all this happened.
Justin: 42:35 So at that point you’ve got to basically really count the cost and say, am I willing to take on all this business headache and hire a consultant and literally build a business and maintain clinical acumen at the same time or come to terms with the economics of the model and continue to live a life with less headache than if you were signing the checks is what you’re saying.
Dr. Grider: 42:54 So that’s why you see a lot of really marginal little pain practices out there because they’re a mom and pop shop and and, and it is yours, but you know, but you never do as well as you did when you were professionally managed. If somebody knows how to create a professionally managed situation like the fellow I was speaking to today, this guy seems pretty sharp that he’s working with and, and it’s a professionally managed business organization that’s different than most medical deals that you ended up dealing with. So anyway.
Justin: 43:22 So in conclusion, Jay, with regards to anesthesia and pain, it’s obviously a very demanding profession and it requires a lot of sacrifice through training and lots of long hours, you know, over the whole course of your career. I’m sure there’s, you can just stack up story after story of the times you were staying late in order to really use your vocation to serve others. So in closing, I’d love to hear a brief story reflecting on one of your proudest moments as a physician that made you glad that you do what you do.
Dr. Grider: 43:48 There are plenty of patients stories, but with regards to the topic at hand today, there was a year that I had three fellows and they were all from very different backgrounds and in the year that we were together learning about business management and those sorts of things, they developed a very close bond. I was able to help one of them establish a very, very lucrative and very, very active hospital based practice and over the following two to three years. The other two migrated from sometimes great distance to work with that first person where three fellows who were in training together went different directions and ended up working together in a seamless group. Just tickled to death to be with each other. You know that. That is a proud moment to me. Whenever. Whenever you create an environment where people liked the way they practice, they liked the people that are doing it with and they liked the spirit and the engagement and they choose to continue to take that culture, make it their own and expanded. There’s lots of successful practices that we’ve helped set up for people, but that’s one way or multiple people were able to benefit from common processes.
Justin: 45:07 Yeah, and I think it’s a great testament to the way that you instill common vision and your trainees and the people who go through there, they’ve got the same ethos and that draws them to one another reason even later as they continue practicing. I think that’s a great, great story. So Dr. Grider, I really appreciate you joining us on the Anesthesia Success podcast. Thank you very much for your time today.
Dr. Grider: 45:27 Yeah. I enjoyed it. Thanks