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Navigating Your First Job: Career Guidance for ENT Residents · Voices of Otolaryngology

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Welcome to the Voices of Otolaryngology podcast series, where we spotlight
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diverse perspectives and insights within the field of otolaryngology.
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I'm your host, Rahul Shah.
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Let's jump into it.
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Welcome to the voices of Otolaryngology.
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I'm your host, Rahul Shah, the EVP, CEO
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of the American Academy of Otolaryngology Head/Neck Surgery.
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I'm here with a new friend.
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Doctor Rivera, welcome.
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Thank you for having me. So happy.
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Happy new year.
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Thank you.
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Same to you and everyone else who's listening.
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Tell us a little bit about your practice, who you are, and then I'll tell everybody
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how I was lucky to meet you.
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A little bit about myself first.
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Prior Air Force.
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And right after Air Force I went to medical school
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and I did a rotation in ENT and fell in love with it.
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And actually, while I was in the Air Force, had a peritonsillar abscess
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that was drained by an ENT, Doctor Golightly.
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He didn't go so lightly on me.
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But you know what?
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He took my tonsils out and cured my problem.
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So hold on.
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Does it hurt to get your own PTA drained?
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Was it painful?
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It was very painful, I can tell you that.
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Not even want to go through that again.
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That's why I had my tonsils out for sure.
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So you had a Quincy tonsillectomy, or they came back and ?
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No they came back later on and, and, took the tonsils out
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because I didn't want to go through another PTA again, ever.
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So you were in the Air Force.
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You had a PTA that motivated you to be an otolaryngologist.
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Well, actually what motivated me was, we had a great instructor back in Nevada.
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I went to University of Nevada
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School of Medicine because I was stationed there
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with the Air Force at Nellis Air Force Base.
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So, he was awesome.
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And I fell in love with his courses.
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And I looked into ENT.
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And fortunately, I got to come back home to Tampa, Florida, where I went,
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to USF and did my residency there.
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And, stayed in town and, stayed on board
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as, clinical professor through the VA and then private practice.
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So I got a little taste of both with, through the VA
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and, the program had offered me a full time job,
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so I had a little bit of a taste of, an offer from an academic position.
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Little bit of taste of academic, you know,
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instruction over the last 22 years with the USF residents.
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Every other Friday, I did surgeries and clinics, and I got to build,
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our practice, which is Florida ENT and Allergy, here in Tampa.
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And we are the largest practice in the state of Florida.
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We we're going to be 30 ENTs in our, you know, group.
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And we have merged with, NTAF, which is statewide.
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And we have 100 ENTs in our group.
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And so all under one ID number.
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Well, thank you for setting the stage of who you are.
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I'll say you're lucky, man.
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You've been military, military medicine, so to speak,
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and then you've been in the academic realm, in the private practice realm.
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And now from a small to mid group to a large group, you've been everywhere!
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And the VA system.
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Yes, sir.
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Yes, sir. I got a little taste of everything.
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You didn't even, from the, PE standpoint,
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in the hospital setting, because when I was searching for a job,
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the baycare,
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hospital system had offered me a job as well,
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so I got a little taste of PS,
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academics, private practice, small group
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and large groups in the last 23 years of practice.
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Well, I'm blessed.
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I met Doctor Rivera at the Florida Combined Otolaryngology meeting.
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Absolutely stunning meeting,
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terrific energy and vibe from our Florida otolaryngologists.
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The exhibitors, the students that were there.
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Kudos to the whole society, and the state of Florida
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for just a terrific, terrific meeting.
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I really enjoyed the legislative session, where you all talked about
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how you use advocacy to drive our members.
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Doctor Rivera and I were having, a little happy hour, and he mentioned
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that he's been very involved
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in educating the next generation of otolaryngologists.
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And I wanted to invite him to Voices of Otolaryngology to
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take his experience, learnings and amplify them.
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So let's just get right into it.
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Doctor Rivera, you've been doing this for decades,
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educating the next generation.
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Tell us about that.
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What should the residents now be thinking of?
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Probably.
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Is it as interns they start thinking
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when do you suggest they start thinking about practices?
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I honestly, when I was, with the residents,
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I started talking throughout all the years, but, hey,
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I know towards their chief years
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when they actually become more interested in what they want to do.
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One thing I told them is that for years, we did not have a choice.
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We apply to college, and whichever college accepted us, we went there.
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I applied to medical school, which was whichever one opened the doors.
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We moved right on.
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And then we applied to residency and whichever residency it was,
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we went right on.
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This is the first time in a very long time,
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after many years of training, and many hours of training,
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that you actually have a choice and the choices are out there.
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But residency is great.
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We can take any cancer out.
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We can reconstruct the, the defects that we leave after a cancer.
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We know exactly what to do.
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We are the best trained ENTs in the world, but we don't get trained
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on the practice of medicine, meaning the administrative practice.
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And what kind of offers are out there.
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So I was able to offer that to the residents and talk about
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the different aspects.
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The pros and cons for each one of the options.
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And one thing I did for them as well is once they decided
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I actually review many contracts with them because,
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even if they didn't join us or they,
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you know, wanted to go back home and things like that,
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I wanted to make sure that the contracts were clean
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so they wouldn't have problems in the future because, you know,
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an experienced surgeon is that of,
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many different, bad experiences or other people's experiences.
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Right. So same with the administrative side.
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One is an experienced person, is one that,
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is a collection of heard bad experiences and practices.
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A divorce after a practice is very, very difficult.
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Separation from a practice.
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Dealing with certain things that were not clear in the beginning and
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dealing with them later actually adds a lot of stress to your life.
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And that's something you want to clear.
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Let me back up because you said something that I love,
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and I had never thought about it. Choices.
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And you said, let's let's address residents
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and the young physicians, those that are just starting to come out.
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So you, in your experience and what you teach them
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is to start thinking, fourth and fifth year, you said intern,
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second year, third year might be a bit too early.
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So when you talk about choices, you go a little bit deeper
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and you suggest they start thinking fourth and fifth year.
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Right.
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Fourth and fifth year, they have to make a choice
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whether they want to do a fellowship. Right?
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So even if they do, they want to do a fellowship.
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Even if you have that in mind, depending on what the fellowship,
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what would be your next step, even though you're not a fellowship?
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I speak with them about where is that you want to live?
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Better yet, if you have a significant other,
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where's your significant other going to be happy as well?
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No ENT has left any town because they can't make it.
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They have left town because they're not happy either
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with the practice or with the place where they moved to.
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So don't base it on financial means, base it more on “where
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you actually going to have a good quality of life?” So let's let's talk to
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I put a placeholder on contracts because we'll get to that.
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So there's choices you talked about.
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Think about the practice setting.
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What else do you think the residents should be focusing on?
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Think like you talked about the fellowship versus not fellowship.
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That's a branch point. Then.
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Then what should they start
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thinking about into the fourth or fifth years looking at practices?
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Correct.
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So one, where do you see ten years from now?
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Do you see yourself teaching residency?
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So you are you looking for an academic position?
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Do you see yourself doing more research and things like I will that probably
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academics even don't try and make it so you can do a lot of research,
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but academics will offer those those avenues for research.
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Do you see yourself as an owner of a practice?
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Do you see yourself as a, you know, employee physician?
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So those are the options that you have to think.
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Because if you're thinking employee physician, well,
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there are opportunities there with hospital systems, with, large
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multi-specialty groups where you don't have any options to become an employee.
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But if you're thinking about have ownership and voice, then private practice
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and either a small group or a large group are the two choices for you.
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I appreciated that.
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So now I'm going to I'm going to keep throwing your statements back to you
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because, you know, I really find them, thought provoking.
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So we have choices.
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And then you said you said something interesting.
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We are trained to handle anything.
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And I really believe that that's the beauty of otolaryngology.
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That's the beauty of our RRC.
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That's the beauty of the AB OTO.
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We're all exquisitely trained.
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But then you need to
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think, you said you need to think about the practice setting.
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Right.
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Do you want to talk a little bit about how you guide the residents
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on thinking about the different kind of practice settings
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and we know they're trained, so that's not the issue.
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It's what they're looking for.
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I don't want to put words in your mouth, please.
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So for example, if they're thinking about a fellowship in Head/Neck.
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Not many privates, private practitioners are doing a lot of Head/Neck.
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There's some out there,
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but overall academic settings are doing most of the Head/Neck.
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And they have the facilities to manage those patients.
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So that's one thing that if they're thinking
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doing about hHead/Neck, more likely looking more academic setting,
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if you're thinking that you don't want the headache of overhead
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building a practice or being a partner, and you want to be an employee physician,
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you can look into PEs,
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because you don't become an owner in a PE.
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And the other ones are,
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in hospital settings because the hospitals actually
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own, the practice and you just become a, an employee physician.
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But also large groups can actually employ
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you as a physician with, without the, partnership track.
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That's something you can do.
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We have a few of our,
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physicians have joined us, and they have no, no interest in becoming a partner.
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They just want to be an Employee Physician, where you give them a bonus.
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They just want to come in, see patients and go home and have their vacation paid.
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And that is okay, because that's your choice.
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And you want to be happy that way.
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But for those who want to have a,
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partnership in a practice,
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have ownership and get something back and be able to collect
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or take home more than a employee, physician will take that opportunity
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there in the small and large, practice groups.
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Private practice groups.
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Yeah.
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One thing
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and I, I don't want to correct you, but I want to point out an opportunity.
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You were using the analogy of fellowships and maybe had an EC.
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You might have to be in an academic medical center.
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But we're also seeing in mid to large size groups, even hospital employed.
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They are looking for those folks to say, look, and I bet you
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your group of 30 could sustain several, solo dedicated head and neck surgeons.
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Or some fellowships. Right?
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You're seeing that at the mid and large groups. Is that fair?
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Correct. It's very fair.
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You have to have a large group to support that.
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And for example, rhinology is one that can go into a large private,
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practice group.
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And. Right, we have to look at some rhinologists who do some skull base
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for the practice as well.
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We have a couple of, facial plastics patients that, train
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physicians that did their fellowships in their in our group as well.
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We have a laryngologist that’s in our group, so they do
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subspecialize and they able to join large, private practice groups,
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and we're able to support those subspecialists because we see
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enough patients that we can actually, refer to them.
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Another one is, we have an otologist and we are,
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in, in, partnership
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with a neurotology group that has three neurotologists.
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And we can support those, those those specialists.
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Head/Neck?
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Actually, yes, some large groups can actually support them.
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They would need
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maybe 2 or 3 in order for them to cover each other and things like that.
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So that's why I use them a little bit about the academics,
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because they're more set up for that.
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But you are right, there's a lot of large groups that can support the Head/Neck
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individual.
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Well said.
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Thank you for painting the landscape.
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From your experience talking to residents and fellows, what they look for.
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So we talked about choices.
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Then you morphed into different practice settings.
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Go a little bit deeper on
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explaining to our young physicians and residents partnership
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or employed in the hospital or employed by a large group.
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You use the word headache.
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I might convert that to opportunity.
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So you, and I know you've really built practices
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and you've had hundreds of headaches for every success,
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but why do people like you then take that headache?
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Why does a Gene Brown in Charleston, South Carolina?
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He's our president of the Academy, or or Doug Baccus, past president
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for a private practitioners that they they do that there's obviously an upside
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but there's a reality.
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You also talk about partnership, right?
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It's not all always good.
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Sometimes you have capital calls.
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You have deficits. It's not easy.
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Talk a little bit about that for the residents and trainees.
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Doctor Rivera.
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Excellent.
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The, when you are a partner and you own the practice, you have a lot of autonomy,
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but you have an autonomy that is is is, it has a paradigm.
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A paradigm is how the
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the group will best work under that paradigm, under those rules.
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But you have an autonomy where you actually later on, when you work
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hard, you have a little bit more time, time off.
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So you're not restricted by, hours in PTO because you are the partner.
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You can take as many days off because you want to,
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as long as you pay the overhead. Right?
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But the return on investment is higher you actually get to take home.
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You can actually, home more on the of the revenue,
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rather than being, bounded by a salary.
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The other thing that is very satisfying with,
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private practice and being a partner
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is that you are ENT and your focus is only on ENT.
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And whenever you need an equipment or something
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that will actually boost our practice to take it to the next level,
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I don't need to convince, another specialty
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to actually approve that or an executive to approve that.
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You are approving it because, you know, this is why you need.
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Certain services that
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probably you would have to, referred out.
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Now, I'll give you some examples.
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Allergy, speech, CT scanners.
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We do VNGs within the practice.
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You get revenue from that.
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In other locations where you are an employee physician,
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those referrals go out
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and they actually you don't get don't receive any revenue from it.
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So ancillary revenue as a as a large, aspect of our practice is now
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that we can actually keep those in-house and we can actually manage them
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fairly well.
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Also, with certain employed
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positions, you're not allowed to be a part of a surgical center.
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So an outpatient surgical center is another, revenue stream that you can get.
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All you have to do is take your cases there,
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then you're able to get some revenue.
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You still have to do the cases somewhere, but,
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and one thing I learned too, is that in the hospital settings,
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when you do your cases, most of your cases have to be done in a hospital.
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That's because they get that revenue.
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For us, whenever we are renegotiating
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a lot of the, insurance payers, they look at where
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we're doing our surgeries
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and a surgical center is a lot cheaper than any hospital place.
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So it helps us not necessarily from a revenue stream point,
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also from a contracting standpoint that actually, will help us
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in our contracts because we're saving the insurance company
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money by taking the cases to a less expensive facility.
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So those are the things, as a partner, that you have so many different avenues
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of, of revenue that later on will come back to you
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and then later on you can actually sell back as well.
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Another one is, it's so many different areas.
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Another one is you can own your buildings and rent to yourself.
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That's another source of revenue.
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And later on when you retire, you have a building that
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probably you can sell back or you get revenue from the real estate.
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And we allowed all the parties
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when they come together to be part of the real estate.
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That's something.
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That's something I tell the residents all the time.
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Make sure that the practice is fair, and they give you the opportunity
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to have the same benefits as us, as the older partners.
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Yeah.
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And the here today I'm trying to present a balanced opinion.
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So whenever you go one way I'm going to pull this back.
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And I think that's great because we want to help the residents with their choices.
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Let me explain something to our trainees and young physicians, if I may.
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I want you to rewind and listen to Doctor Rivera about ancillaries.
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What I hear out there from our private practitioners
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is reimbursement for physician services are going down.
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But what's saving practices are ancillaries.
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Doctor Rivera listed several of them.
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And you all can go through and talk to your your faculty
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and your rotations, but it's the ancillaries that help you.
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Another word for ancillaries is downstream revenue.
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If you're in a hospital setting,
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as a head and neck surgeon, let's say you might have a CT scan.
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You might have an office procedure that doesn't always come back to you.
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The second thing Doctor Rivera mentioned was real estate.
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And he colloquially said, pay yourself back.
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But what he means by that is, if Doctor Rivera and I are partners,
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then the rent check
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is written from our group, Rivera and Shaw Partners,
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and then we own it in an LLC or we own it, whoever owners they are.
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But with that comes responsibility.
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You have to pay the taxes, you have to pay overhead.
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And if the real estate market goes down.
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So you talked about the positives there of partnership.
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Talk to me about the positives of, you said: some people join your groups
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or other groups to receive a steady paycheck, to get four weeks of vacation,
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to not have to worry about the fluctuations.
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Partnership is hard when Medicare gets cut by 10-15%, partners feel it.
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Or if there's a lawsuit.
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So talk to me about the attractiveness of being an employed
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physician in a larger group such as yours or others.
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Right.
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Some of the benefits in a multi-specialty group,
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and they hire you as an employee physician.
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If they have primary care physicians, they actually will.
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You will have a referral source.
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That's one of them.
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So you're not really competing.
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You are the choice for the group to actually send to you.
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One, just like you said, is when everything's fluctuate and trust me on it.
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During Covid, that was a scary time for a lot of practice practitioners,
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where, actually, we as partners came, sat down and I would say we as sat down,
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we made same choices that any executive would have done with any other group.
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We had to cut here and there and shifting coverage and all that stuff.
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But those are the headaches I'm talking about.
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But we were doing so well before, that we have enough reserves
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that all the partners were comfortable during that time to be able
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to withstand the pressures of the time.
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And if you're an employee physician, well,
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there's one advantage is that, well, you're not responsible for the overhead,
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but one disadvantages, if those executives see
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that they actually need to cut costs completely,
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they can completely release you as well during that time.
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So there's two risks there.
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As a partner, you're not releasing yourself
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and you're waiting for it to pick up again and you're on board.
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But, on these, groups, they actually release,
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some, some physicians at the time or cut down their salary as well.
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I've seen that they give,
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certain promise salaries.
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Then, they review your performance based on either collections
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or RVUs On the RVUs is the most commonly used or anything like so.
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And after 1 or 2 years, they come back and sit with you,
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and they let you know whether
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you're actually sustaining the salaries they give you.
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And I know for a fact that there have been times that when they said
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that we need to cut your salary down because your RVUs
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or your collections do not support the the salary that we gave you.
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I when I want to back you up.
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Because I'm going to forget to ask you this
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because I want you to explain to the residents, before I have you explain,
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I want you all again to listen to what Doctor Rivera said about Covid.
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We are now almost five, six years, four years out from Covid.
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So there's a whole generation of residents that were probably in med school
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during Covid. And.
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And we feel bad for you. It is really hard.
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But I want to state something that's a basic fact
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to many of us that were practicing during Covid.
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Partner salaries were cut and some didn't get paid for 3 to 4 months.
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Some never got paid because the insurance company
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said, I'll pay later, that that window is expired.
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So it was really hard, for practices to cover costs, keep paying their rent.
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Remember, you said you pay yourself the rent for the building?
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Well, where does that come from if you're not generating revenue?
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So I want I want our residents and young physicians
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to understand that it's not always a glory days.
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Being a partner. There comes big responsibility.
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Doctor Rivera, could you explain very briefly,
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RVUs versus revenue for the residents?
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I don't want to insult anybody, but, you know, maybe fair target, 7
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to 10,000 RVUs. What does that mean?
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Just please pull this back and educate them a bit on that.
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Right.
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For every procedure, everything you do, there's established value.
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That's what the RVU is.
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Established value of what you should get paid.
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Okay.
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So just say that, you know,
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you get a specific amount for a tonsillectomy based on the RVUs.
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But that not necessarily
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means what the insurance company is going to pay you for it.
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Okay.
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So RVU is an established value.
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And what the many systems do is they say,
23:52
okay, you're going to work for us here on their salary or base your salaries.
23:55
Will we evaluate you based on the RVUs.
23:58
But it's just a number.
24:00
The collections is a different thing.
24:03
So we do ours and bonuses are measured by collections.
24:08
And the reason is because collections is really what pays the bills.
24:13
So you can charge.
24:15
Let's just say I'm using a tonsillectomy as an example.
24:18
You can charge $1,000 for the procedure,
24:21
but this specific payers said
24:25
we're only going to pay you $200 for it.
24:29
So that's all you're going to get is $200.
24:32
But the RVU say is 300.
24:35
So it doesn't matter what the RVU says, I'm getting just $200. So
24:40
systems that are larger, like hospital systems,
24:43
they just want to use a very universal number.
24:47
And that's what they use the RVUs.
24:50
Practices, they pay the bills, they usually use collections, not charges.
24:56
So to make to to make the distinction,
24:59
the charges were $1,000.
25:02
The RVUs was 300 bucks,
25:04
but the insurance paid us $200.
25:08
So for us a true number is $200.
25:11
That's what you brought in.
25:12
And we'll base your salary and your bonuses based on the $200.
25:17
But, and we're not going to get into the economics of practice.
25:20
But Doctor Rivera is being very generous, I would say, because there's overhead.
25:24
And that overhead can run 30, 40 all the way to 70%, 80%.
25:30
So out of that $200 that I brought in for Doctor Rivera,
25:33
it's got to pay the biller.
25:35
It's got to pay the front.
25:36
It's got to pay the RN. It's got to pay the MA.
25:39
So actually from that $200 and don't quote me any overhead
25:42
numbers, but, you know, you and I know it's 25, 30% up to 70, 80%.
25:47
Let's say it's 60%.
25:48
So that means in that tonsillectomy
25:51
I've got now $80 that I generated.
25:54
I just want her folks to hear Doctor Rivera loud and clear.
25:58
So when the trainees, residents, young physicians
26:01
think about that, they're different compensation models.
26:03
You earlier talked about contracts, and I promised you we'd go back there.
26:08
I'm a resident.
26:09
I'm a fellow.
26:10
I'm overwhelmed.
26:11
Contracts are confusing.
26:14
I don't know who to trust.
26:15
What advice do you give them?
26:19
Two advices.
26:19
The main advice before you get to the contract
26:23
is when you meet the physicians, see how transparent they are.
26:28
Number one, meaning financials.
26:32
How are the partners doing when they come over?
26:35
I open a spreadsheet
26:37
and I show exactly how they did the last two years for the partners.
26:40
What should I look at, Doctor Rivera I'm just a surgeon.
26:44
I'm just a resident.
26:45
I've never read an Excel spreadsheet.
26:47
I hear this all the time from students I mentor.
26:50
They get overwhelmed.
26:51
What are they looking at?
26:52
They just want to see how the practice data is it revenue?
26:55
Is it take home? Is it overhead?
26:57
Just a couple thoughts.
26:59
Very good.
26:59
The three things that I show is the overall, performance
27:03
of the entire practice over the last 2 to 3 years.
27:07
Okay.
27:07
So that way you see whether the practice is doing
27:10
better, a drastic decrease or anything like.
27:13
So I gives you a little bit of,
27:15
just a sign, a vital sign of the health, the financial health of the practice.
27:19
And number two, what is your net?
27:22
So after
27:22
paying the overheads and everything, what did the partners take home?
27:25
Okay.
27:26
And that's important because that's what you're going to invest
27:29
into and see whether well that net taking home
27:33
it's a lot higher than being an employee physician.
27:36
So let's again let's not assume anything.
27:38
We we love our trainees.
27:39
They just haven't used these words before.
27:41
So let's take the tonsillectomy example.
27:44
The charge was $1,000.
27:46
The gross revenue to the practice was $200 because that's
27:50
what ABC insurer decided to pay for it per your insurance contracts.
27:55
Your overhead was 60%.
27:57
So the net for the surgeon for the tonsillectomy was $80.
28:02
Can you check me on all those things? Do I say it right? Okay.
28:05
It's the net.
28:06
It's the $80. Correct. Please, back to you.
28:07
I didn't mean to interrupt you, but I just wanted to define that.
28:09
So you want to look to 2 to 3 years of financials, please.
28:13
Perfect. Perfect financials.
28:15
What the partners took and then what is your time frame to become a partner?
28:20
Okay. Time frame to become a partner. And
28:24
what is the eligibility to become a partner?
28:28
Once you become a partner, are you going to be an equal partner or lesser partner?
28:32
Okay. Do you have a voting right.
28:35
And then what is the partnership cost?
28:39
How much is it going to cost me to become a partner?
28:43
A buy in is what we call it.
28:45
They have that clear and cut. That's great.
28:49
If they say, well,
28:52
3 to 6 years or anything like.
28:54
So they're kind of fluctuating about it.
28:56
What what makes it three, what makes it six?
28:58
You guys decide what are your objective data that I could keep up with that.
29:04
Actually I know whether I'm going through the partnership.
29:07
I'm going to meet those partnership goals or thresholds.
29:11
And number two is I mean, and then, once I meet it, what is the cost?
29:16
Let's just say x amount in that.
29:19
How do I pay that x amount?
29:20
Is it through overhead
29:21
or is it a check or is it a, you know, line of credit or anything like so.
29:25
So they're clear cut.
29:27
Not that you're already working three years
29:30
and all of a sudden you're in limbo.
29:32
Whether you're going to become a partner or not, you're in limbo.
29:34
How much are they going to charge you for partnership and you're in limbo.
29:37
How are you going to pay into it?
29:38
So those have to be fairly clear before you set up for a contract.
29:45
Wow. Again, folks, if you're listening to this, just back up
29:48
and you know, he's going very fast but incredibly insightful.
29:52
Thank you for helping them
29:53
think about different ways they even, pay their partners out.
29:57
That was very eloquently stated.
29:58
And you might have left some examples out
30:00
because you were just rattling off the top of your head.
30:02
So we made one more.
30:04
Thing I would like to include, though. That's the financial aspect.
30:07
The other one is the partnership aspect, meaning morale aspect.
30:11
So a good question would be: has anyone left the practice?
30:16
And why did this person leave the practice?
30:19
And then if they did, is it okay if I can reach out to that individual?
30:23
And that's important because if they're reluctant to tell you
30:26
why or anything like so in the reluctance for you to call that individual,
30:29
maybe they're hiding something, right? I do.
30:32
I tell them exactly how many we started, how many we are,
30:35
the people who left and why they left.
30:38
And if anything, here's their phone numbers and give them a call
30:41
and just ask them any questions about the practice.
30:45
If it worked out for you, it didn't work out.
30:47
But what was pros and cons for the practice?
30:50
I think it's good to be to be open
30:53
because you are about to get into a marriage.
30:57
Into a marriage with partners, and the divorces are not pretty.
31:02
One of the awesome things about our specialty,
31:05
and this is why I'm in it, and probably why you're in it.
31:07
When you rotated a med student, you feel this free decor.
31:11
They're smart surgeons, they're wonderful doctors, but they're really nice.
31:16
And I've never met an otolaryngologist who wouldn't take a cold call.
31:19
So I really like what you said, Doctor Rivera. If
31:23
somebody calls me and says, hi, my name's Joe Schmo.
31:26
I'm a resident at this program, and I'm looking to join Doctor Rivera's group.
31:31
And I notice you left last year.
31:33
We would take those calls. Do you agree?
31:34
Our peers are great otolaryngologiss,
31:36
and we always want to help the next generation.
31:38
So don't be shy.
31:40
Residents and trainees, heed Doctor Rivera's advice.
31:44
Call them.
31:44
Go back to the contract.
31:46
You and I've done this. We've mentored.
31:48
I mentor several every year.
31:51
And the contracts are pretty standard.
31:53
They're 40 pages long.
31:55
A lot of them are non-negotiable, and they're non-negotiable.
31:58
You just said there's 100 physicians
32:00
in Florida ENT & Allergy, you can't have 100 versions of a contract.
32:04
So this is not legal advice.
32:07
Should they all run out and get a lawyer?
32:09
Should they just shut signing with their eyes shut?
32:12
What do they do?
32:13
I've seen both ways, and I don't know what advice you give over your decades.
32:17
I always recommend to have someone take a look at it.
32:20
The chances of them changing anything major are very little, like you said,
32:25
because if we do an exception to one, you weaken
32:28
the other 99 contracts that we have under NTAF So,
32:33
but if it's something about bonus structure, if it's something about salary,
32:38
maybe partnership track or anything like so
32:41
there's some, leeway on that.
32:44
On negotiations, whether you were fellowship
32:47
train, fellowship training, what you want to do and things like that.
32:50
There is some on that.
32:51
But as far as you know, when it comes
32:54
to non-compete, starting
32:58
any, any type of reasons for,
33:03
letting go someone or anything like.
33:06
So those are pretty standard.
33:08
We can't change those, especially non-compete.
33:11
Non-compete.
33:12
You want to watch for non-compete that are really extreme.
33:16
You know, the whole state of Florida.
33:18
There's no way there's no reason to do that.
33:21
If there is some protection for the non-compete, because you build a
33:25
practice, you're building that individual, you're building their practice,
33:28
and then for them to leave and build up a practice
33:32
across the street from you, you got to have some protection from it.
33:35
But if you're doing counties and things like that, that's extreme.
33:38
And it's not, it can be held in court.
33:41
So watch for those things.
33:43
And remember, folks, this isn't any kind of advice.
33:46
It's just Doctor Rivera and Doctor Shah chatting.
33:48
Anotherr word you see for non-compete is called restricted covenants.
33:54
So if your restricted covenants says you cannot practice
33:57
in the United States of America.
33:58
That's overly egregious.
34:01
Are you allowed to say or do you have a ballpark,
34:06
your experience, just your experience.
34:08
And I'll give you my experience of what a lawyer usually costs?
34:12
You know, so these residents and trainees,
34:14
you know, they're making a certain amount of salary.
34:15
We know that, how much is it cost?
34:19
I think I'm I'm going to give you my opinion.
34:22
I agree with everything you said, and I, I agree, have a lawyer look at it,
34:27
and then it just gives you a discussion.
34:29
I go back to Doctor Rivera and say, well, Doctor Rivera, can you explain this?
34:33
What is my lawyer think?
34:35
It doesn't mean they necessarily change it,
34:37
but a lawyer can help flag for you based on your individual circumstances,
34:40
how to guide you.
34:42
How much should the resident budget for this?
34:45
And you don't have to give a number if you don't feel comfortable.
34:47
But no, I I've seen that some of them already have friends
34:50
that actually do it, and they do it for them for free.
34:53
But you know, anywhere between $600 bucks to $1,200 is what I've seen.
34:59
If it's $600 bucks, is it worth it for you
35:02
that they're picking up something that is really.
35:05
No doubt. Out there?
35:06
It's it's it's worth the worth the money for the peace of mind, actually.
35:10
So I would tell them just review it and have someone review it.
35:13
That's why
35:14
I offered to review a lot of these things with them
35:16
when they have contracts from outside of the Tampa area,
35:19
which I just reviewed, as a feedback, not necessarily as competitive,
35:23
and just help them out with that. Yeah. Agree.
35:26
Similarly and I the number that I've seen and maybe it's just
35:30
I don't know I mean I counsel or look at people across the country.
35:33
So I've seen 2000 to 2500 is a max.
35:36
So you and I are in the same ballpark and it's really money well spent.
35:39
Would you agree? It just gives peace of mind.
35:42
These are money well worth it.
35:44
And it makes them if they come in convincied and trustworthy,
35:48
it's a completely different ballgame.
35:50
When they have they have trust in the practice
35:52
that they're actually doing in the right practice.
35:55
And I think it leads to a wonderful discussion.
35:57
Doctor Rivera, why is the restricted covenant,
36:00
covenant
36:01
five miles from this office, but not from this office?
36:04
It just it's a good discussion to explain why
36:07
the investment that the practice has made in that office, the capital.
36:10
There's always a reason, right?
36:12
It's not just whimsical.
36:13
You don't make this stuff up for fun.
36:15
I'll give you a really good example and is a really good question.
36:18
Is that and one of the difference between private practice and, some
36:23
of the hospital settings is that the call you have to have privileges
36:27
in certain hospitals and you have to pull call, ER call.
36:32
And in order to keep privileges in those locations,
36:35
hospital system, they will hire you, but they will not pay
36:39
you for, the call.
36:42
Some of them are doing some now, but the most part,
36:44
they say it's included in your salary and as your responsibility.
36:48
Private practice?
36:49
We do.
36:50
We negotiate a call, stipend per day.
36:55
So what we do is,
36:58
is 50% of the call stipend goes to the individual
37:02
just to make sure that they get something for that call stipend.
37:05
The other 50% goes towards the bonus calculations.
37:09
Right?
37:10
So their first question is, well, if I'm doing all the work in the call,
37:13
why is it that 50% is going towards my -
37:16
towards the practice and then utilizing the bonus calculations?
37:20
And that's when I my answer is, well, you're under salary
37:24
while you're on call, you're restricting the number of clinics and patients saying
37:28
because you want to be available for the hospital, that 50% compensates
37:33
for the cost of doing business in the practice.
37:36
Once that answer is out, they understand it.
37:39
110%.
37:40
And those are things most of us don't think about when we're residents.
37:44
The cost of doing business Thank you for sharing that example
37:48
because I didn't know where you're going.
37:50
And I'm like, wait a minute, doesn't sound right.
37:51
But then as soon as you said it, it makes perfect sense.
37:54
So that's an awesome example of just a dialog that a lawyer
37:57
might have flagged and said, hey Rahul, take a look at this and ask the group.
38:01
So thank you for sharing that personal example from your practice.
38:05
Two more things and then we'll start wrapping up.
38:08
There's a workforce survey.
38:10
AJ Tompkins chairs the Academy’s task force for the work force.
38:15
And you can go to ENTnet.org.
38:18
2023. 2025.
38:20
We've published updates to our workforce survey.
38:23
And you're quoting a lot of those facts.
38:25
And I know you have them in your head, but I'm sure you would agree
38:28
to the residents and trainees, please, folks, read these workforce surveys.
38:32
It gives you an idea about call, compensation, structures, anxillaries.
38:37
So I just want to put a plug for that.
38:38
I don't know if you want to comment on that.
38:40
And then I'm going to ask you for a couple of key takeaways.
38:43
Reflect on your slides and make sure we haven't missed anything.
38:46
Doctor Rivera, first workforce survey I don't mean to put you on the spot,
38:49
but it's a wonderful tool to help our trainees think.
38:53
Yes, I think they should review it.
38:55
Take a look that way you go into interviews
38:57
with a good knowledge base of what it is out there, and
39:03
your value.
39:05
Like I said, we're well-trained
39:07
and we go out there and, now you're going to the place
39:11
that you want to go, but actually you want to be compensated for what you value is,
39:16
and that workforce survey
39:17
is really going to help you with some of those questions later on.
39:20
Yeah, I really like that.
39:21
That's a nice way to start thinking about how we wrap this up,
39:24
because at the end of the day, your career is your most valuable profession.
39:29
And you now you've had
39:32
the choice to make there.
39:34
What have we missed that you like to when you think about that, our talks,
39:38
you give in all the hundreds of hours of mentorship you've given.
39:41
What are we missing?
39:42
And maybe you want to summarize some key takeaways.
39:45
If you have an elevator pitch to a resident or fellow,
39:48
give us a couple minutes of key takeaways.
39:51
Key takeaways.
39:54
There is a lot of time and sacrifice to become who we are.
39:58
There's then a lot of time and sacrifice to do what we do
40:02
through the emergency room, taking care of patients and stuff like that.
40:05
There's a huge value, and my fear is that if we lose
40:11
autonomy and we lose private practice,
40:14
then we are at the mercy of people telling us what our value is.
40:19
And I think that's why, even though I get a lot of the academics
40:23
through the, through the VA system in USF, University of South Florida,
40:28
private practice has been, very influential.
40:32
And I've been very, very active through the Florida society
40:38
to maintain the autonomy on private practice in order for all of us
40:42
in the future generations to actually get the value for what they do.
40:50
Wow, that was so beautifully stated.
40:52
It's it's not about RVUs.
40:54
It's not about dollars. It's not about contracts.
40:57
It's about value you bring to your community and members.
41:00
What a wonderful summary.
41:01
Doctor Rivera, I want to thank you for being a new friend, for everything
41:05
you do for Florida, for your practice, and for our specialty.
41:08
This was awesome.
41:09
Maybe we bring you back in six months if you want to continue helping
41:13
educate our next generation of residents, fellows and young physicians.
41:17
Love to.
41:18
And thank you for the opportunity to, express this.
41:21
I've given this lecture at the Academy, a couple times
41:24
and at the Florida Society almost every year.
41:26
Well, wonderful.
41:27
Thank you very much, Doctor Rivera.
41:29
Thank you. Thank you.
41:33
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41:34
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41:39
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41:41
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41:47
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