Part 2 What is your Worth Maykel

So welcome back all you BTK fans. It's Scott here for part two with Dr. Justin Makel, professor of surgery at UMass Medical Center, division chief of colorectal surgeon. And Justin, welcome back to BTK. Thanks. I'm excited to do this again. So Justin, where we last left off, you just kind of gone through a little bit about an example where we were feeling good about ourselves as surgeons good median salaries you reminded us a little bit about the taxes and a little bit about the loans that many of our trainees and many of our early surgeons may have but You know what?

I wanted to jump into in this second part of this podcast was to talk a little bit about the other variables and then What do we do about this in terms of really kind of saying how do we negotiate and what does that all involve? So let's jump right back in right there. Yeah, sure. So, we talked a little bit about some benchmark data some average median salaries and you know

how valid they are talked a little bit about costs associated with life in general taxes But there are other, there are other factors at play that impact in surging income and and we can't forget about gender and race equity.

And unfortunately, this is also seen in the healthcare arena where women are played, paid less than men still in 2024. So probably somewhere around 15 to 30 percent. Left where I think we're doing a better job, but it really needs to be a focus moving forward to make sure that the gender pay is balanced and it's worse for black and Hispanic women.

Fortunately it was not seen extensively in the A-S-C-R-S survey, but again, that was limited by sample size. So gender and race equity are are still issues that we need to address. There's no question that there is a peak in earning sort of mid career, sometime, somewhere around age 50.

And so it's probably your highest earning ability is

around age 50, where You know, you've been in practice for about 20 years, you've established yourself, you you have a lot of leverage in your negotiations, and you're active and enabled to generate significant RVUs. And then it tends to tail off over time.

So years in practice is important, again, sort of peaking around age 50. And then depending on where you practice geographically, so there's absolutely no question that surgeon salaries are highest in the Midwest probably in more remote communities where surgeons need to be attracted by higher salaries, whereas salaries are the lowest on the East Coast.

And it's significant. So if you look at the A. S. C. R. S. competition survey, the East Coast median compensation is around 383, 000, whereas the Midwest is as high as 410, 000. So, it's a significant difference in seeing there. We talk a lot about, you know, the, I'm working in an academic medical center versus on private practice.

What role does that, the type of practice you have in this? And let's

just say, let's forget about the fee for service, let's just say salaries in general. Yeah, so it's evolving. There's no question about that. A lot of the benefit that comes from surgeons who are in private practice is that they can share a lot in the facility fee or revenue generation on that side of things by owning surgery centers so that as being part of an organization that owns, for example an endoscopy suite, you can you can generate revenue just based on the volume of business that's happening.

You can significantly increase Increased salaries as well. One of the struggles that we have is that despite inflation, and at least at my medical center, every year we get an email coming out saying how, most employees at our medical center's salaries are going up by three 4% to to stay up with inflation, but for whatever reason, the surgeon's salaries don't, are excluded from that.

Baseline increased on an annual basis. Now, hopefully, compensation models will be reflected in compensation models. But again, when we're looking

at MGMA data and other benchmark data, it doesn't necessarily always reflect, you know, the changes that are necessary in order to keep up with inflation.

Yeah, I think that's a really good part, especially when, you know, for many people, all of this, getting your first real kind of salary, if you corresponds with potentially getting married or having kids or, even a little bit later in life, you get a bump up, but you know, kids tuition, going to school, going to college, buying a house, all these other factors that go into it in terms of just living.

Yeah. There's a lot of delayed gratification, right? So. I didn't get my first real job right until I was 33 years old, by the time I was done with all my training. Whereas my college friends, they've been You know, generating significant revenue since they were in there, you know, early to mid twenties.

And so number one, you're behind the ball. And then number two, like we talked about earlier, a lot of people come out with significant student debt that you need to you know, that's another line item. And then you're, like you said, you're

buying a house. You're trying to save money for for not only retirement, but also to put your kids through college.

If you're married and you have children. So a lot of the money that you're bringing in, you're either, you have expenses or you're putting it aside and you realize that the end of the day, you don't have a lot of disposable income. I think it's very interesting when we talk about, you know, just using you, for example, you know, the differences in the stages of life between.

And again, we love our profession. I'm not saying that we don't. It's a good idea, but it's important to keep these things in mind. Your own children, who are just going through this entire process in a different field outside of medicine, but compared to, you just said you're what, you were 33 or whatever when you made your first job.

Yeah. And pay scales are different. And I think that people, you know, there are a lot of people who are choosing different fields in different industries and not going into medicine because they see the struggle. They see the commitment, the time. And at the end of the day, they can make significantly more money by putting the same amount of time just in different fields.

And so I think we need to

be cognizant of that. And as we think about the future of healthcare and we think about negotiations and ways to keep physician salaries up, we have to think about the fact that we want to attract the best and the brightest to go into healthcare. I want good people taking care of me when I get elderly.

And I think that this now is the time to address this and realize that at least from a financial perspective, we really need to focus some value on physician salaries. Yeah, absolutely. And again, I know we're talking specifically about salaries. We love our jobs.

We love the things we could do in the honored privilege that is to operate on patients. And I never forget that and always make sure our trainees know that, Justin, there's also things that as you can go into a little bit more about, you know, there's Revenue generating activities that we do as a part of being a physician, but there's also some things that don't actually necessarily Are taken into account for what that all involves.

That's exactly right. We when we think about at least in academics and in the focus of You know, my career, your career my,

my division, it's really about, patient care, research, education, community service, right? But beyond all that, and sometimes actually interwoven into it, there are different roles, different jobs that we can have as surgeons that can provide a lot of fulfillment and can and can allow our careers to evolve and take us down different pathways.

But can also generate some additional revenue on the side. So, for example depending on, what your scenario is at work, you might choose to pick up some moonlighting shifts to take some general surgery call or trauma call and make, you know, 1, 000, 1, 500 a night taking some call. You might get involved in a medical malpractice review as an expert witness that you can generate revenue from.

I've had the fortune of working alongside industry industry partners as a consultant that, you know, I think helps to advance our field, but also, provides me with an opportunity to see things from a different perspective but also that can be an additional role for practicing surgeons and

physicians.

You know, we can benefit from philanthropy and fundraising. So, for example, if you're fortunate enough to hold an endowed chair at a medical school, then you are the one who is receiving that unrestricted, you know, 4 percent of a 1. 5 million gift that could give you about 60, 000 of discretionary income to help people.

You know, advance the missions of your division on an annual basis. There are intellectual property opportunities. And like we talked about earlier, particularly in private practice, facility ownership. And so there are a lot of different revenue streams that we can focus on. I think it takes a little bit of time to understand that and then to get involved with it.

It's not so easy to jump right into that after after you finish your training, but there are a lot of different pathways we can go down as our careers evolve. Yeah, those are all great points. And again, it may be. In evolution over the course of your career not necessarily something that you may jump into but opportunities exist in that Let's transition now into you know Something that some people are absolutely fantastic at and others may

feel a little bit wary of approaching this Especially when they're so excited to get a job Maybe you're fresh out of residency or fresh out of fellowship and that's the negotiation process Walk me through that Yeah, so, you know, we are fortunate enough to have a colorectal surgery residency training program at UMass Memorial.

I've been able to help mentor a lot of our graduating fellows as they work through this process. And one of my key messages to them is that really for the first time in their careers, they're in the driver's seat, right? So in general, you feel like, you know, you're telling people what they want to hear as you're applying to medical school and residency and fellowship, but it's really the first time you can make that transition to say, okay, well, what is it exactly that I want to do?

What am I looking for in a job? And actually I'm bringing a lot to the table. I am a valuable person and I'm going to make your team better. And I tell them, I said, listen, like you are the cream of the crop. You are a first

round draft pick, and you need to start thinking that way and acting that way.

Because this is your opportunity to set yourself up for your first job. Obviously, you need to do it. Like, there are parameters. You need to do it respectfully. And negotiation is about both sides, you know, being happy. But remember, there are opportunities for negotiation. And you shouldn't feel uncomfortable about that.

You've put a lot of long years into this. You've worked hard for it. And it's finally time for you to negotiate that first job. Okay. So now it's your time to be able to do that. And you've said a little bit of about the back work of that. So let's walk through. So you come to me, I, you know, I'm involved in a lot of these particular ones and, depending on where you're at and what your job is, there could be a pretty boiler plate approach to it, you kind of, just like when you go to sell your car, you got the Kelly blue book out there.

And as we talked about, you could find some starting salaries out there, but. Okay. Different compensation models. Walk me through some of these, and again, I know that we're going to cover these in a couple of the other podcasts, but let's walk through there

first. Yeah. So, I mean, it really depends on what stage in your career you're in.

Right? So, you might be talking about your first job, or you might be talking about negotiating in your current role, or you might be talking about making a mid career change to a different location, or even getting a job offer and then coming back to your current job and, you know, asking them for a change as well.

So, there's a lot of different scenarios out there. But when we looked at that ASCRS compensation survey that we talked about earlier, Unfortunately, about a third. of surgeons were either very dissatisfied or dissatisfied with the amount of their compensation. So in general, this is creating a lot of angst and people are interested in figuring out ways to do better.

And so compensation models vary from institution to institution. Now, the standard design is that a doctor will or a surgeon will have a base salary. And then beyond that, there is a production bonus. And so when I talked to my, you know, colleagues

outside of medicine or friends from high school or college, it's like, wait a second, like you get paid more based on the amount of work that you do.

So like, this is like a real job. I said, yeah, this is actually a real job. And it's that medicine is a business. So just be, so we all understand that. So what that means is that you can generate more money based on doing more work. And so typically it's a. It's a an amount of money dollars per view beyond some type of a set threshold, and that threshold can be a lot of different levels.

And again, it depends on the institution and the dollars per view that you make beyond that is a negotiated option as well. The issue with these types of standard base plus. product productivity bonus models is that it really does reward production over quality. So it falls on the surgeon to make sure that they're doing a good job taking care of these patients.

And there's no question that we, there's a level at which you can go beyond and then you can probably not do as good of a job paying attention to

detail, making sure that, you're crossing your T's and you're dotting your I's. And everybody probably has a different, you know, called a plimsoll line, right?

So that level of the boat where the boat starts to sink when, you know, the boat gets overweighted. In addition to that, some of these models in the context of a team don't encourage teamwork, right? So you and I are partners together and I'm trying to steal business and get more business so I can make more money than you.

It's probably not a good thing as it relates to our relationship. So there are a lot of there are a lot of bonus plans where there's some shared revenue. So, for example. If you do more than your partner, then maybe you only keep half of it, and then you share the rest with you with your partners.

It also disincentivizes time off, right? So the more you do, the more you make. And we already know about the issues of physician burnout and people not taking time off, but we don't want, you know, we don't want that to go overboard either. Yeah, I find it very interesting in terms of one of the jobs I had how my partners were actually my competition.

I never thought about it that way, but it's certainly something that can come up depending on what your plan

and what your practice is. Obviously, if you're straight salary, some of this stuff doesn't apply. We all recognize that. But all right. So you're out there. You're ready to go in. You're all amped up.

How do I prepare for that negotiation? Yeah, so, well, there's a lot of things you can do. So obviously like everything we do, the first step is to arm yourself with knowledge. So you really need to understand, you know, your particular situation. You need to understand you know, your organization priorities.

So you want to really research the market, right? And so you. You know, like you need to understand the data and be able to go in with it to negotiation with that. You want to create an argument for yourself, right? You want to highlight your value. You want to track your achievements. You want to update your CV.

You want to leverage your skills. You want to do everything possible to show that you're a leader and that you have a lot. You're bringing a lot of value to the organization. And then you want to use that to it. Prepare a really compelling case and, practice your pitch. Talk to your colleagues.

Maybe call, a mentor and say, Hey,

listen, I want to talk this through. Let me tell you what I'm planning to do. Give me some ideas. And then you got to choose the right time, right? So if your institution isn't doing well, they're in the red, they're doing layoffs. It's probably the wrong time to go in and say that you're looking to get, you know, more money.

One of the problems in health care is that. There are a lot of people who are what we call professional interviewers, and they spent a lot of time going around interviewing some jobs, getting job offers, and then using that to leverage and, you know, an improvement in your current role. And so, unfortunately, people feel compelled to do that because when they go for a negotiation and they ask for more money or more vacation time or less call or whatever it is, they That they're looking for.

The answer is no. And they say, Okay, well, then I'm gonna go out. I'm gonna get a job offer somewhere else. And then they're gonna, basically negotiate with me and give me what I want. You know, that is one approach. Unfortunately, I think it you know, people are forced to do that. I think having a relationship where you value one another and you

figure out ways to grow together is way more productive.

And to do it in a collaborative fashion, I think is a much better approach. So how do you convey to your providers or to your potential bosses? What's your worth? Where would they be without you? Yeah. So, just speaking as a colorectal surgeon who works at an academic medical center.

You can just step back and look at the big picture and say, okay, so how would my institution do without a premier group of colorectal surgeons as they're taking care of patients with rectal cancer or inflammatory bowel disease in the context of a multidisciplinary team? Or overarching programs like a cancer center or an IBD center or marketing campaigns that really, you know, talk about the innovative care is being provided by robotic surgeon or who's going to train the general surgery residents and the colorectal fellows who are part of your program or how does the medical

school exist without, you know, a diverse, surgical population.

And then one of the big things that I talk about all the time is the concept of. You being the portal of entry for patients into your medical. So once you've been somewhere for a period of time, and you've developed a name and a reputation, and you provide quality care, and you have relationships, then all of a sudden they're referring docs, whether they're primary care doctors, gastroenterologists, other surgeons.

Instead of sending them to the hospital across the street, they send them to you. And then those patients are plugged into your medical center, and there's the concept of downstream revenue. And so take, for example, a rectal cancer patient. So if a patient gets sent to me as a rectal cancer specialist, well, all of a sudden that patient is now going to be going for radiology studies, CAT scans, MRIs, they're going to see medical oncology and radiation oncology.

And then there's significant downstream revenue that the medical center realizes because the fact that they referred to you. So you are the portal

of entry into the, into your healthcare system. And I think that's a really, really important. Piece of information to convey so let's reset a little bit Let's take me all the way back if I was to kind of go back to the original question What is your financial worth to your institution if you were to buck it into a couple of things?

Kind of give us a summary here. Yeah, so, well, that's a good question. I think that you know I think that understanding number one that a busy colorectal surgeon provides About a 1. 5 million of cash into your medical center's pocket every single year. Is a very important piece of information to have.

Number one. Number two I think it's important for people to know what the other people at their medical center are making and what they're generating for revenue and what their salaries are, and that's very difficult information to have, but I can tell you that most possible

administrators are probably bringing salaries higher than you are.

And you know, obviously it's variable from. From site to site and in no way am I being critical of my current role or my medical center because I'm super pleased and happy and I feel valued and satisfied in my role. But I think it's important to know that. And so. Any any nonprofit organization, their tax filings are publicly available.

So you can go online and you can look at the tax filings for your medical center and see who the highest paid individuals are and how much they make. And so, you know, Sometimes they're even published in the paper, so I can tell you that the CEO of our medical center made 3 million last year. And I can tell you that the CEO of Mass General Brigham made over 6 million last year.

You know, it's in the Boston Globe. This information is all publicly available. And so, just to at least have that as a framework, I think it's really helpful. We also can look at, you know, some of the other groups of people who are paid in your medical center. So About, I don't know,

six or seven years ago, our nurses union was going to go on strike, and so as part of that, our medical center published some information in our local newspaper, and that information was that the average nurse at UMass Memorial made 135, 000 a year, had 37 paid days off a year, And we contribute 60 million dollars to the retirement fund on an annual basis for the nurses And so when you step back and you think about you compare yourself right to Other employees that your medical thing you realize that you know You are at a point where you could probably negotiate if you feel like you're being underpaid

So just and there's probably some other things though as you go into this negotiation that maybe extend Beyond salary. And again, I know we'll cover this more in detail in one of the other segments, but can you go into those other possibilities that you can be armed with kind of walking through?

Absolutely.

So, I think at the end of the day, you have to sit back and think about what, you know, what's important to you. The salary is only one piece of it, and I'm sorry that this is like so salary focused, but I think it's like the one thing that most people feel so most lost about. But if you think about negotiating a role it's much beyond that, right?

So it's about a lot of different things that might be important to different people. So whether that's a better balance more time off, less call or block time, perhaps supporting you to get an advanced degree, whether it be an MBA, for example protected time for doing research or or for for teaching you know, sometimes there are even stipends that come with titles and academic promotion.

And so if you think about career advancement, work life balance. Your ability to provide quality care there, there are a lot of different things that you might negotiate in order to make your situation one that's better for you, not for just for the short

term, but for the long term as well. Yeah, absolutely.

And again, as we talked about, this is just a clinical aspect of it, but there are others that might have some administrative time and research time and all the other things that are built into it. It also depends. It also depends on like, like, again, what we're talking about, like, What do you like? What?

Where are you negotiating? Is it again? First job? Is it second job? Is it making a move? Is it staying within your institution? Is it trying to figure out like your next, you know, second step in leadership advancements? And so, there are definitely some, like, sort of benchmarks, what I would call low hanging fruit.

So when my fellows come in to me and they say, Listen, I'm negotiating for this job, they want to hire me, I'm just going to accept the offer. It's like, well, time out for a second. I, you know, are you getting moving expenses? Are you getting a signing bonus? Are they giving you fringe benefits like, practice allowance and how much they're giving you, they're going to send you to meetings.

Like there's a lot of just basic stuff that almost every job should be providing an early surgeon. And then there may be

others that, go beyond that. So are there meal plans? Is there low interest loans? Can they help you with purchasing a house? There's a lot of different things that you might like look into as you consider a different job or when you're, putting one job against the next.

Yeah, no question. And some of this stuff can range anywhere from a couple thousand bucks upward to 50, 000 or more depending on what your stage of your career and what you've asked for, especially if you're talking about things like tuition assistance. Yeah, you shouldn't feel funny about it either. Say, listen, I, you know, I'm just finished with my training.

I've got a quarter of a million dollars in loans. I need to move across the country, can you help me get started? I, you know, I need a down payment on a house. And I think that when you frame it that way and you realize that, this is this is an opportunity for for them to basically be recruiting you and bringing in talent to, to grow their division or grow their department.

That it's really a win win. I think that's the most important piece of any negotiations that both sides feel, you know, positive about it at the end. Yeah, and I think it's worth

saying and up here is that don't be surprised if some of the answers are no though Like especially on the stage you're going to say well, I may do this.

I may not do that i'll get you here. But no we can't do that You know and you might find that more early in your career where many of these contracts are boilerplate Absolutely. You definitely have to be flexible You have to be willing to take no for an answer But I think it's safe as long as things are reasonable just to ask and you know The worst, you know, the worst response is no right So justin it's been a fascinating walk through this two part series here with you To talk a little bit about what is your worth?

So give me some conclusions wrap this up All right. Well, I guess I would say that you know, you're probably as a busy surgeon who takes great care of patients. Has good quality outcomes, is a leader and wants to drive a program forward. You're worth way more than anyone's going to admit.

And and if I were going to give you some solid numbers, they would probably

be inaccurate because it's really hard to know. Exactly what we're worth. When you look at the big surveys, the median income for a busy general or colorectal surgeon is probably in the range of four to 450, 000. But again, that's based on studies and in survey data.

That's not all that valid. I say number two, you're your best advocate. Do your best to get the benchmarks. But do it in a very professional manner, respectfully, and do it without emotion and and do what you can to feel like you're advocating for yourself and for your family. Number three, I say it's important to reassess your value at specific intervals.

So that might be a certain number of years in practice at a time of academic promotion. But remember, probably your best opportunity for revenue generation is somewhere around 20 years of practice or somewhere around each. Some people, unfortunately, really realize their worth when they threaten to move.

And although I said

earlier, I don't like that approach. It can be, you know, the most, Successful way to negotiate a change in your current role. I'd rather do it in a mutually beneficial relationship, but that's not always possible. And then I guess the last thing I'd say is that, I think we do have an opportunity to do a better job of getting Real world data.

And so if there's an opportunity for a group of physicians that really come together and potentially do things anonymously and figure out, like, you know, what are You know, your income variables as it relates to base salary bonus compensation, RVUs, where you work geography, geographically your age your sex and your race.

And I think, you know, those pieces of information would be super important to have in a manner that we felt comfortable that they were accurate. I think that if we did that, I think people will feel more comfortable with their current compensation. And potentially, it may be one of those

situations where You know, the tide rises for everybody.

Yeah, it's no question. And salaries are hard to talk about, let's face it, in any profession, and especially in the So give me one final take home point to kind of wrap this up. Yeah. So at the end of the day, you know, Scott, this is really about job satisfaction and overall life satisfaction. It's not about the money.

It's really not. It's not about like, comparing yourself to somebody else feeling, unvalued if you're making 10, 000 less than somebody else, it's really about being satisfied in your role. Feeling that you're valued, having flexibility from a work life standpoint, having job security, the work itself, your career advancement is critical.

I mean, as I look back at my career, probably the most satisfying app aspect of it has been my career advancement in different roles and how it evolves over time. And then the working conditions, it's really about the team that you build and the people that you work with, because let's face that you spend more time at work than you spend at home.

That's fantastic. And Justin, thanks so much for taking the time

on behalf of all the listeners to walk us through an absolute fascinating topic. And one that we honestly don't talk that much about. So for all of the listeners out there, dominate the day.