This is the final installment of a 2 post series. In part 1, we covered a lot of ground, including:
- We described the context of Dr. Slowburn's situation.
- We reviewed why the common legacy exemptions to call based on years of service or age may be inadequate or create an undue burden on newer, younger physicians based on flawed assumptions and skewed age distributions.
- We asked questions to assess the relative strength of the hospital in negotiations.
- We discussed how cooperation among specialists can improve negotiating power with hospitals and insurers alike.
- We considered how Dr. Slowburn and his colleagues might entice a seasoned specialist transitioning to retirement to partially offset the burden of call, perhaps via a locums physician.
What options exist to survive outside of the hospital ecosystem?
It might not be what Dr. Slowburn had envisioned for his medical practice at the outset, but there seem to be more options for financially successful medical practices outside of traditional hospital-based systems.
Surgical specialists enjoy multiple alternatives to continue operating provided they are willing to give up performing the more complex surgeries within their scope of practice.
Hand surgeons can make a living on surgeries done exclusively in ambulatory centers. Plastic surgeons can make a living from day surgery cosmetic procedures. Ophthalmologists can earn well with an exclusively lasik-based practice.
For family medicine and ER docs who can't take it any more, urgent care or telemedicine may offer a lower stress alternative with better control over hours. For primary care docs, anti-aging medicine, weight loss and office-based medi-spa procedures remain options. Dermatologists have built the ultimate playbook for providing medical and cosmetic treatments in office-based practices.
Dr. Slowburn's level of burnout, degree of interest, family needs and desire for income will all help to determine if any of these options outside of the hospital-based ecosystem are worth considering.
Tackling the elephant in the room: the free market option.
The reason call sucks is because it doesn't pay enough to be worth the hassle. The solution is simple but not easy: pay more for call.
Easily demanded if the hospital foots the bill, but what if Dr. Slowburn and company are on the hook for paying the premium? How might he and his colleagues determine a fair market rate for call?
The math is not hard, but collecting good data depends on honesty and transparency by all. Determining market rate may be potentially undermined by collusion among those looking to pick up shifts (they can conspire to artificially inflate the price of giving away a call shift) within such a small community of specialists.
Send out a survey with two columns to the other specialists.
Column one contains the following:
At X price I would be willing to give up Y call shifts.
Rewrite this statement going up by $100 bucks a shift in multiple rows and see how folks respond.
Column two varies the wording ever so slightly:
At X price I would be willing to pick up Y call shifts.
Rewrite this statement going up by $100 bucks a shift in multiple rows and see how folks respond.
If the money is sufficient, folks will put up with the hassle.
When you arrive at a price where supply of call shifts to be given away meets demand of call shifts to be picked up, yahtzee! You've just determined market rate for a call shift.
Note that this may vary by season and holiday, and any scheme to buy out of call should account for this variability. Ever been able to get someone to take your call on Christmas? No? There's a reason for that.
What if Dr. Slowburn's colleagues will only accept significantly higher payments to pick up call?
Time for Dr. Slowburn to use his FI superpowers and significantly reduce his expenses so he won't miss the extra money.
He might also try exercises to determine a financial exchange rate for the freedom less call will buy him: If I earn 20% less annually buying out of call shifts, but I'm able to work an additional 7 years thanks to reduced burnout, will I come out ahead or behind?
Then again, there are certain rewards that can be challenging to properly value in financial terms. After Dr. Jordan Craig cut back, she observed, "I sleep 10-12 hours on my days off. The sleep has been integral - this was a huge part of my problem in hindsight. My memory feels sharper and I am so much more patient."
A purely financial analysis may vastly underestimate the true value of getting out of call. If Dr. Slowburn is close to his FI number, he may afford this luxury more readily than his colleagues, placing him at an advantage in buying out of call shifts.
What if no amount of money turns out to be enough?
Unlikely, although theoretically a job may prove so toxic that no one will work one iota more than necessary, which begs the question: why are you working in such a job?
What's more likely is that the amount of money called for is more than Dr. Slowburn may be willing to spend.
Again using the example of Dr. Craig, she was willing to take a 50% pay cut, downsize from her doctor house, and significantly reduce her consumption via the embrace of a minimalist mindset to eliminate the major aggravations in her practice of medicine in one fell swoop.
It's perfectly okay to decide that you are incapable / unwilling to make such radical changes in your lifestyle. Accept that this unwillingness to change will mean you'll still be on call.
Physician On FIRE will leave his part-time job as an anesthesiologist at age 43 in the summer of 2019. A key part of his strategy in achieving enough at such a young age was designing a lifestyle where enough could be quickly and easily reached.
Those who have enough, as the White Coat Investor has pointed out, shift their emphasis to improving and maintaining their health through diet, fitness, social supports and adequate sleep.
Dr. Slowburn may decide that the price of investing in his health earlier by improving his undisturbed sleep outweighs the drawbacks of reduced income.
Buying out of call as a young physician may be possible, but expect to pay dearly for the privilege.
Are there ideas I missed entirely or considered unfairly in my analysis? Please chime in under the comments section!
I'll ask that you keep the discussion to the logistics of brainstorming fair solutions to call.
Comments 6
Working longer for less money/yr than burning out quickly with higher income per year will almost certainly lead to a higher lifetime monetary accumulation.
The progressive tax code and phase out of deductions further penalizes the quick burn high income case making the true difference in earning/yr even smaller.
It took me awhile to figure out that nugget of knowledge but have since applied it to my favor by paying someone to help reduce my clinical time.
Author
Xrayvsn,
If in doing so you assist that person taking clinical time off your hands in accelerating their path to FI or eliminating debt, it can be a virtuous cycle. Happy to see you leveraging your position of strength, my friend.
CD
I my group when we were at the hospital, I analyzed the amount of money we made on call vs the amount we made on the schedule. Call hours produced about 40% of the income. If you wanted easy hours you could get 7-3, 5 days a week and you could get 60% of one slot plus you pay your share of the practice overhead. The remaining players divided the remaining 40% n-1 ways. The decreasing divisor provided the income boost. We had a couple “takers” over the years but the “takers” provided endless bitching over their choice.
Author
I like the way your math worked out in your group. In the end, it seems human nature inevitably emerges along the lines of “Such terrible food, and such small portions!” despite the fact that the buffet you;d designed was self-service.
I’m not a surgical specialist but I’ve seen a lot from the other side of the ether screen. As noted, the best solution is to get out of the hospital and into a surgery center or office environment if at all possible. Beyond the examples presented, I’ve seen a urologist develop a busy out-pt cysto & lithotripsy practice and a young orthopod thrive as a sports medicine guru by marketing himself to any and all youth and adult sports organizations in the area.
If you can’t escape the hospital setting it’s going to cost $$, either in lost hospital payment (if any) or actual cash payment to the call taker, possibly both. Obtaining free market pricing data as described is a good idea if the hospital staff is large enough but the reality may be the pool of potential call takers is often limited. The negotiation may end up being one on one and it helps if the potential call taker is young, hungry and in debt. That would be the likely description for a fellow as discussed in Part 1, but anyone on the staff with privileges is a potential trade partner. Regardless, if you’re able to arrive at a trade price with another surgeon that’s just the cost of doing business. Realistically, this can decrease the call burden but getting rid of it entirely is difficult without leaving the hospital system.
On the other side of the screen I have a lot of experience in minimizing call duties. I was formerly in a large group practice with a lot of potential trade partners. The reality though was that only a few considered taking extra call for pay, most would have been delighted to reduce their call. My main advantage was I had a plan and was closer to FI than most of my other partners so I could and would pay more to get rid of a call. There was definitely a free market that I could use to my advantage by willingly outbidding others to entice someone to take my call. The essential value factor at play for me was Time>>Money. Since reaching FI, I’m no longer with my original practice but now at a part time job in a surgery center. The pay rate is lower but my satisfaction is significantly higher. Good luck to Dr. Slowburn in finding a workable solution.
Author
GasFIRE,
You examples of docs who left the hospital ecosystem is encouraging, if understandably hard to duplicate for most physicians.
Each one of us needs to figure out his or her unfair advantage in reaching FI – high income, high savings rate, frugal or dirtbag tendencies, or even front-loaded savings that (in your case) allowed you to outbid for the scarce takers of extra call.
You are correct that while everyone wants to get out of call, only a select few are prepared to pay dearly for the privilege. That was your unfair advantage before you moved to the surgery center, and it appears to have rewarded you handsomely. The secret is building a life where you don’t miss the money.
Thanks for weighing in,
CD