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IC25-L: Managing Burnout/Moral Injury

Moderator(s): Melissa Arief, MD

Faculty: Orrin I. Franko, MD, Noah M. Raizman, MD, MFA, Mark E. Baratz, MD and Simon G. Talbot, MD

Session Handouts

76th Annual Meeting of the ASSH

September 30 – October 2, 2021

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

mailto:[email protected]

9/24/2021

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Picking and Starting a Practice

Orrin Franko, MD

2-person Private Practice

East Bay Hand Medical Center

San Leandro, CA (SF Bay Area)

Disclosures

• I love my practice

• I want you to pursue private practice (if it’s right for you)

Fundamentals of Practices

• What sets Practices Apart?

• Finances of Practice

• Challenges & Opportunities

• Finding the right job…

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My practice…

What is “Private Practice” ?

• Doctors own the practice• LLC or S Corp Partners• Income beyond salaries becomes “distribution”

• Control over…• Office personnel / management• Clinical patients / demographics• Personal life / days / hours of work

• No restrictions over other opportunities• Research / Ancillaries / Call / Locums• Ownership of intellectual property• Real Estate ownership

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I NEVER hear the phrase…

“…you people….!”

Practice Models

Solo Practitioner Single Specialty Group Multi Specialty Group

Office-Sharing Fixed / Variable Equally Divided

Size/Type

Overhead

None Some / Shared Complex / Shared

Ancillaries

My PracticeEmployed

Income Streams

Practice Income

50%

Hospital Call Stipend

20-30%

Ancillaries

15-25%

Other*

Volume: Marketing, Referrals, OutreachContracts, Efficiency, Coding & Billing

Overhead, Overhead, OverheadRejected claims

Regional competitionContracts

Insurance Legislation

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Income Streams

Practice Income + Hospital Call

50%


30%

Ancillaries

15%

Ancillaries: ASC + Therapy

50%





Income Streams

Practice Income + Hospital Call = 30%


30%

Ancillaries

15%

Ancillaries:ASC, Imaging, Therapy, Real Estate

70%





Income Streams

Salary + Production Incentives = 90%

Work more Competition from partnersCall = 10%

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Overhead Income

60% overhead…

How Employed Overhead Works…

40% income…

25% increase in collections =

25% increase in income

Months

Overhead Income

Months

FIXED overhead…

How Private Overhead Works…

VARIABLE income…

25% increase in collections =

50% increase in income

$40,071

$42,720 net

$39,419

$56,669 net

$32,916

$87,724 net

16% ↑ Collection33% ↑ Income

45% ↑ Collection105% ↑ Income

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Lifestyle

• Level 2 Trauma Center

• General Ortho Call ~4 days/mo

• Hand “Activation” call ~10 days/mo

• 9am – 4pm with 1 hr for lunch ~25 patients/day

• Thursday afternoons off

• 3-4 vacations, 3-4 conferences, 4-6 long weekends

Practice Mix & Volume

• New Patients = 30 min, F/U Patients = 15 min, + emergencies

• About 25-35 patients/day in office (3-3.5 days/week)

• Surgery 1-1.5 days/week

• Average 8-10 elective cases/week (low-average for hand)

• Combination of routine vs. complex cases

• Hospital call / Hand call

• Average 4 consults / week - often at convenient times

Private Practice 401K

• 11-13% invested annually surpasses Kaiser pension value

• Plus the benefits of….• You OWN the entire portfolio (your heirs inherit residual value)

• You have FREEDOM to use it• Early withdrawal if necessary

• Alternative investments

• Control over investment choices

• You have EQUITY in the practice / ASC / Ancillaries

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Retirement FundsFor more info: www.whitecoatinvestor.com

• There is no “pension” like some employed positions (Kaiser)• Kaiser pension is worth ~12-15% of your annual salary• Ex: $440k at Kaiser = $500k private practice

• Let’s do the math…Kaiser pension: 2% per year x first 20 yrs, then 1% per year.Assumption: Start at 35 yrs old, salary of $440k, work until 65 yrs old…Pension = 2% x 20 + 1% x 10 = 50% salary x $440k = $220k / yr

Payments start at 60-65 yrs, increase 8% each year deferred Payments until death or death of spouse (I think) Lump sum payment for amount above IRS limit $1.5m (est) Still have options for 401k contributions

How about if you make $500k? 4% withdrawal rate =

$219,595 / yr

AND…..

You still have $5m in the bank!

Challenges & Opportunities

• Managing Employees

• Controlling Overhead

• Strategic Decisions

• Insurance Contracts

• Income inconsistency

• Self Promotion / Marketing

• This can be mitigated with • Great office managers

• Consultants ($$)

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Office Set up

• “Low Overhead” means no extra staff• Room your own patients

• Perform your own flouro exams

• Remove / wrap your own casts

• Dictate your own notes (template + Dragon)

• Code your visits

• Patients LOVE it

*Efficiency tips discussed in other lectures

Where to FIND a JOB?

• There is no “job board” for areas in need…

• Example from my area:

2 general orthos retiring within 5 years with busy hip/knee/shoulder practices

Aging (and shrinking) call pool for general ortho and trauma at Level 2 hospital

Three surrounding ASCs that are all profitable

If you called asking for a “hand-only job” Sorry, we can’t support you

If you called for a general ortho job with call EASILY make $1M+ within 2-3 years

This is my Summary Slide

• There are GREAT jobs out there

• The BEST jobs are not “posted” anywhere

• Get in the room with the right people

• Cold call practices

• Be open to change and new opportunitiesTaking call, work comp clinics, med-legal

• Talk to friends, colleagues, acquaintances, and attendings

• When you start practice – be AWESOME and build your reputation

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Midlife InflectionMark Baratz

University of Pittsburgh Medical CenterPittsburgh, PA

[email protected]

Disclosures• Integra: Royalties. Speaker’s Bureau• JBJS, JSESAm & British, JHS, Hand: Editorial

Boards• Board AFSH

None relevant to the content of this talk

Interviews

• 6 surgeons: 8-19 years in practice• 3 men/3 women

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Three Questions

• Challenges of Practice• Challenges at home• How you see the future

Common themes

• Practice booming• Kids getting older and more active • Less time with partner

Challenges of practice

• Harder to get home• Harder to get away• Pressure live up to rep built on being

available and affable

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• Current behavior not sustainable• Is there a ceiling at my institution

Unique to current events

• Covid fatique• Frustration with antivaxers• Longing for return to normality

Family

• Struggle to be present for everything• The only mom to miss school events

• Missing stuff on call• Enough quality time with partner

• Will we survive this?

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How I see the Future

• Generally optimistic…if can make changes• Get practice partner• Protected time

• To coach kids• Be more available for kid functions• Time with partner

• Should I limit my practice• New community• New institution.

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