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Hacking The Kaiser Permanente Physician Career

Kaiser Permanente is a large and growing HMO which many west coast physicians are familiar with. They offer very competitive pay for their physicians and are incredibly competent at making doctoring very efficient. They hire MD’s, DO’, NP’s, and PA’s.

While each department has some autonomy, the physician group as a whole is treated equitably, each specialty having a set pay based on specific metrics. There is a chief for each department, a medical director (PIC, or physician in charge) for each clinic and there might be some APIC’s (assistant PIC’s).

 

The Kaiser Permanente Model

It’s interesting seeing physicians from the private practice model enter KP. They definitely struggle a bit at first trying to learn how KP operates. In a way it’s really different from other large medical groups and the quicker you can assimilate the concept of KP, the easier you’ll have it as an employee.

Physicians Are Employees

Many are familiar with the partnerships which most medical groups offer. Kaiser, too, offers the option to its physicians to become partners but KP doesn’t really offer a productivity model. In fact, besides some job security and slightly better benefits and a slightly better pay, there isn’t much benefit to becoming a partner.

The medical group gets its operating budget every year from the health plan (Kaiser Permanente is 2 separate entities) and there might be a little left over each year that gets distributed to partners by the March of the following year – it’s in the $10k range, nothing impressive.

An HMO

The obvious point is that they are a HMO. They are both the healthcare provider and the insurance provider and as such their goal is to minimize spending by aggressively enforcing preventative care. They have a very impressive operating capital and own all of their own facilities, radiology centers, blood banks, dialysis centers, and are slowly acquiring all of their own surgical centers.

Their business model is shockingly solid. So when my physician colleagues complain to the chief as to why Kaiser Permanente doesn’t just build more clinics, I wonder if they have any insight into the company they are working for. Spending some time getting to know the business model of our employer is worthwhile, helping us make better long-term career decisions.

Once you build such a large system it’s really tough for it to fail (Enron?). The biggest risks to a large organization is having rogue leadership or shady bookkeeping. At Kaiser the physicians in leadership are selected by the physicians who have voting rights (partners or shareholders).

Medicare Backbone

Like most medical groups, it’s important for KP to be reimbursed for services offered to their large number of medicare patients. And though it may not be as big of a deal how well you document certain things and which billing code you use for the majority of the patients, it’s critical to capture the diagnosis which are reimbursed by medicare.

Pharmacy

Medications are ordered in large quantities by KP and therefore incredibly low prices are negotiated on mostly generic medications. We don’t give out samples and we don’t have drug reps trying to brainwash the clinicians.

There are a few patients who have health insurance plans requiring them to use outside pharmacies, but that’s rare. Pretty much everyone gets their meds at KP pharmacies and we have a strong mail order pharmacy system which is sadly underutilized.

Even better, our pharmacist have their leadership intertwined with physicians who together decide on how to best curb medication abuse, antibiotic overprescribing and cost cutting when it comes to medications being prescribed unnecessarily (think albuterol for URI).

The Southern California Permanente Medical Group (SCPMG) had shockingly weak pharmacists in the outpatient setting. But in their defense, their workload was absurd and not sustainable. After I transferred to the NWP (Northwest Permanente) group in Portland, Oregon I got to interact with brilliant pharmacists.

Unions

Pretty much everyone except for physicians is employed through unions. Even PA’s and NP’s are often hired under unions. The pharmacists and these affiliate clinicians are under the leadership of the health plan and not the physician group which makes coordinating practice models incredibly difficult. It also creates a bit of a divide since physicians will need adopt any change as soon as a memo is sent out on it while affiliate clinicians wait until the union negotiates it down to some permutation of the initial memo.

That said, the affiliate clinicians which Kaiser Permanente hires are fucking stellar. I think that some lose their fire since they are limited by their unions as much as KP is limited by the unions.

I’ll repeatedly express my regret for healthcare professionals working behind unions in this post. In a way this is advantageous for KP in the long run because they will eventually move to automate most of their costly services. And unions are incredibly costly to manage, maintain, and negotiate with.

At other groups, pharmacists and RN’s are used as extensions of healthcare providers. The function practically independently and help guide clinicians. At Kaiser, they are place-holders and in my biased opinion, they have become so complacent that they are rarely of use to me when I need to consult them.

While KP constantly tries to widen the scope of practice of each group of healthcare workers, their unions often push back to preserve the status quo. Something as simple as putting a check mark next to a patient’s name gets contested by the union representatives of the patient registration clerks.

As my good tech entrepreneur friends recently pointed out, anything that can be done by machines will be automated in the next wave of economic turmoil. It doesn’t matter if it’s a police officer giving tickets, an RN administering chemo medication, a pharmacist reviewing medication with a patient, an MA taking vitals from a patient. or a physician taking history from a patient. A fabulous book on the topic to read is this one.

How come physicians aren’t in unions? Good question.

Emergency Rooms

Each Kaiser Permanente group has their own hospitals and thus emergency rooms. Controlling how many patients end up in the emergency department is becoming a bigger and bigger topic of discussion.

Not only is it harmful for the patient to be managed in the ED due to the necessary, extensive workups but it is also financially draining on an institution.

For quite a few hospital groups, the ER is the main money-maker. Patients with good insurance are admitted to the floor and the insurance billed heavily. For KP, keeping patients out of the ED is important to keep costs down.

A patient who can be managed outpatient with good follow-up will almost never have to endure the long waits in the ER, nor get exposed to the sicker, contagious individuals waiting in the waiting room. Furthermore, they get to save money because their co-pays are far higher for emergency visits than outpatient visits.

 

Controlling Healthcare Costs

As someone who has worked in a teaching institution, a private group and an HMO, I find the KP model to be the most sustainable. You won’t find nephrologist managing non-obstructive kidney stones with serial CT’s and stent placement. Primary care physicians can easily handle managing such straightforward medical issues without doing unnecessary intervention.

Toe fractures and concussions are competently and expertly handled by primary care physicians as well. Hint: don’t do fucking primary care at KP, it’s too much work. Do urgent care, so much easier, so much more fun.

What constitutes an emergency visit in other groups is handled by KP effectively in the urgent care. Abdominal pain, lacerations, fractures, some chest pains, and fevers are handled in the outpatient setting.

Unnecessary Shit

There is a fine line between evidence-based medicine and traditional western medicine. It’s often better to lean towards practicing evidence-based medicine since it will curb healthcare spending and decrease unnecessary medical intervention and hopefully give the patient a better healthcare experience.

But of course there is plenty of room for expert opinion as well – that’s what I would call the art of medicine. I have shadowed a few of my ortho, derm, and ENT buddies and I have learned so much from them.

KP is great about disseminating worthwhile practice tips between departments. This has helped decrease unnecessary referrals to ortho for knee pain, insulin management that can be handled without a specialist, and less costly management of low back pains.

What I also don’t see much of at KP are unnecessary knee scoping, excess imaging of the lower back, shitty sinus surgeries for no good reason, wild-wild west oncology treatments and overzealous inpatient admissions.

Interdepartment communication

This has to be my favorite part of the KP, being able to reach any specialist at any time regarding any patient. I have worked in a ton of medical groups and never encountered this level of teamwork.

I admit, working at SCPMG, the Southern California Permanente Medical Group, was a bit chaotic at times and physicians were pressed for time a lot more. Getting a phone consultation still took place seamlessly but there was always a bit more ego on the phone than I cared for.

Here, at NWP, Northwest Permanente, I have encountered some of the most competent specialists on the phone and also have been able to communicate with them digitally through secure text apps which has made relaying information much easier without disrupting the flow of the urgent care.

If I can talk to the oncologist about a certain issue a patient is having, I can gain relevant insight which will help me not only treat the patient more efficiently but also avoid unnecessary interventions and expenses.

 

The Pay Scales

Even though the physicians’ salaries aren’t public information, it’s quite easy to figure out how much each physician earns based on their specialty, seniority and overtime hours.

For example, if each primary care physician starts at $200,000, they will get $X/month for being board certified. $X/month extra for each year they have been in practice out of residency. $X/month extra for their leadership roles, etc.

Generally, there is quite a bit of room to pick up extra shifts in the outpatient setting. This may not be the case with every specialty department since they go through a lot more flux than the primary care departments.

The work you do as a Kaiser doctor is easier than the work you do in the private world. Though you are likely going to be busier with non-patient matters such as doing the inbasket and completing forms, your pay will be much higher for the same volume of patients. However, your pay will max out unless you pick up extra shifts, and there is only so much of that you can do.

Unfortunately the burnout rate or the potential for burnout will be much higher when you’re working for such a large organization.

In the private world, you can certainly earn a high income but you would also have to work a ton more and see a lot more patients. If you are an incredibly efficient clinician, it might be more profitable for you to wrestle that tiger than row your boat in the KP world.

 

Retirement Packages

If you work full-time, I can’t think of any physician who earns less than $250k a year at KP. This means that it’s perfectly possible for damn near every doctor to get the IRS maximum retirement contribution of around $54,000/year (as of 2017).

This might be a combination of a 401k, 401a, Keogh, matching, cash balance plan, or traditional pension.

Some groups will even give you health insurance as part of the retirement package if you spend enough years with them. Usually, if you spend at least 20 years working for them, you will get health insurance from age 65 until your death.

The Pension

Pensions are disappearing exponentially in the job market outside of healthcare. They are expensive and their failure rate can be high.

Large medical groups are going strong when it comes to pensions. Though many are converting traditional pensions to cash balance plans (which aren’t real pensions), these are still quite beneficial to doctors.

There are vesting rules, as with any pension, which is somewhere around 3-10 years depending on which KP group you sign up with and what year you started working.

 

Getting Hired

KP is strict about who they hire. They are risk averse and prefer to stay away from applicants with major issues on their records. However, foreign medical grads in good standing and those who are otherwise competent should have no trouble getting hired.

For the most part, I would say my colleagues are better than average and I really enjoy working with them. Very rarely do I encounter someone who is a complete nut-job. Personalities aside, KP does a lot of internal auditing and monitoring to make sure that their physicians are performing well. My many, many, many clinical mistakes over the years have rarely gone unnoticed and any feedback I’ve gotten from them has helped me improve my game.

No Jobs Posted

KP is a massive medical group. Everything is compartmentalized and it’s really easy that a job that was supposed to be posted never got posted or is in que to make it past legal before getting the A-OK to get posted.

Apply – call – apply again – follow-up – apply one more time – call and email. Yes, that’s the process you may have to follow if you are applying to a really competitive KP group such as NorCal or SoCal.

If no job is listed then apply as a per diem and let them know that you would like to come on part-time or full-time or whatever it is you want. Chiefs have some local power to create job positions even if they aren’t listed. Make sure to let them know why you would be a good fit.

If you can swing it, get someone you know at KP to refer you up to the chief. I’ve had the best luck contacting chiefs directly when applying to different departments and different Kaiser groups (I’ve moved around in departments and locations over the years).

One thing I have learned about KP is that they are ALWAYS hiring. If you can’t get a job as a suitable candidate it’s probably because you ain’t hustling hard enough. Don’t be afraid to oozie out some emails until you ping the right person.

There is always more room for income

I don’t know what it is about HR but they always quote 25% lower than what you’re actually going to make. Maybe they don’t want to make promises they can’t hold.

In the primary care world, forget about it, you will have more extra income opportunities than you’ll know what to do with. Now, if you decide to swallow the poison that is primary care and actually take on a patient panel, well, that’s your problem. But if you come on as a float, an urgent care doctor or take on some other non-committal role then you’ll be able to work in many other departments.

As a specialist you will get the opportunity to pick up a colleague’s shift, work overtime, do extra surgeries, do rounding, etc.

I want to mention admin work as a way to get extra income. It all depends on how much admin you do, your specialty and high up the ladder you climb.

 

Hacking The System

Let’s get juicy. I already mentioned how to land the job and what to expect once you get hired. Next, let’s talk about how to make the job work to your advantage.

Fly under the radar

As a physician the best thing you can do is fly under the radar. Don’t piss anyone off, especially the unionized staff. They can file harassment charges against you even if you just come across stern to them. And they are in a union, so they pose a greater risk to KP than if your ass got fired – remember that KP is risk averse.

Don’t make major patient mistakes. Sure, we all are going to make normal patient mistakes but don’t make gross patient mistakes – in other words, don’t be negligent. I have only had 1 negligent patient mistake in nearly 10 years at KP and honestly, I don’t know why I wasn’t more cautious with her. Thankfully the patient didn’t have a bad outcome.

Don’t piss off patients. If you constantly are getting patient complaints because you’re getting into it with them then you’re gonna get talked to. Don’t do it. Keep the fight on the tennis court or at home with your family.

Be a tool!

KP isn’t the kind of organization you go to in order to start a mutiny. If you want to lead innovation take on leadership. Stop arguing with everything that comes down from management. These people know how to run a successful organization and you complaining about the system will likely just put you on someone’s radar.

Take On Leadership

This isn’t easy to come by because it has more to do with a connection, with nepotism than with competency. Case in point, I had a leadership role at KP and looking back I am realizing what a shitty job I did. Not because I didn’t care but I didn’t know how to be a good leader/manager.

Leadership offers a higher income and a break from clinical work. The leadership skills you could acquire will help you drastically in your future. And yes, leadership will also offer you some job security, though we already discussed how to not get fired.

Max Out Your Retirement

You’re a highly paid employee, you have no tax saving strategy options available to you expect for deferring your taxes into the future by maxing out your retirement accounts.

Accept the fact that there is a lot to the retirement plans that you don’t understand. So when given the option to max something out, do it. You’ll be happy you did. And then read the shit out of this site so you know exactly what retirement accounts can do for you and what they can’t do.

Get Vested

It’s like traffic laws, just because you didn’t know about them doesn’t mean that you can get out from under the ticket. The same holds true for vesting. These complex retirement systems (401k, 401a, cash balance, plans, Keogh’s) require the medical groups to put vesting contingencies in place.

Vesting refers to working enough years with a minimum of annual hours in order to qualify for that benefit’s equity. The annual hours are often set at 1,000.

For example, I need 10 years with KP in order to vest in my pension. I worked only 8 years with them and then decided to retire at age 39. I am not vested in that pension. And I won’t get a portion of it – doesn’t work that way.

Most of the retirement benefit plans have some sort of vesting tied to them. Find out what they are, get the details, review them with your financial adviser and be sure to check the requirements off. AND, after you met the minimum vesting schedule, contact your HR or benefits department and confirm with them that you are vested.

You Can quit and come back later – if you’re in good standing

Let’s say you work for KP for 5 years and you vest in some of the retirement accounts but not all. You decide to quit and give your underwear modeling career another shot. If you can leave on good terms then you can come back after realizing that you’re too fat and too hairy to be an underwear model and pick up right where you left off.

There are 2 ways of accomplishing this.

Option 1, you ask for a leave of absence. You would get no benefits but if you return within 12 months (rare exceptions it can be longer) then you can pick up 100% where you left off – same job, same positions, same benefits, with the same incompetent staff who will ignore your requests.

Options 2, you just quit and leave all your retirement stuff in the accounts which they are in. The reason you want to do this is because if you leave them be, then you can come back and pick up right where you left off, even if it’s 5-10 years later. Again, assuming you are in good standing.

Use Your FMLA

Look, whether you want to use it or abuse it, it’s up to you. But use it when it’s appropriate to do so. If you are going through some shit and calling out a lot or dealing with a medical problem or having your man-opause, get that shit filled out and do it right. You don’t even have to use it and KP is incredibly helpful and supportive when it comes to helping you through the FMLA process.

The reason I am telling you to do this is that you protect yourself by having a FMLA. Furthermore, it gives your chief an idea as to how much they can count on your time and whether they should hire someone else.

Start As a Per Diem

“Nah man, they ain’t hiring, they are just looking for per diems!”

Seriously?! Okay, imagine you are a large medical group and you don’t want to hire some soon-to-be patient molester and you have a limited hiring budget. Legal is telling you that if you hire someone it’s impossible to fire them.

If you are the chief then you’re gonna be picky as shit, right? So, what you do is bring on per diems. And if one of the per diems really stands out then you’re gonna offer them a full-time gig. I am blown away that my specialty colleagues who are dying to work for KP can’t figure this out!

If you are hired a per diem and can’t turn it into a part-time/full-time gig it’s only because something is wrong with you. Could be your ugly face, maybe your foul breath or possibly your vaguely unpleasant demeanor – or whatever you want to tell yourself.

You Won’t Get Fired – except…

There is only 1 way KP can fire you as a doctor … 1 surefire way they can give you the boot and throw you onto the curb with your disposable stethoscope landing on your head, and that’s if you abandon a patient. 

Abandoning a patient can have different meanings but it could be refusing to see a patient on your schedule or leaving during your work schedule for no valid reason. Yes, that’s happened, and yes, they got fired.

You won’t get fired for patient mistakes. If someone told you that a KP doctor got fired for a patient mistake it’s because they aren’t also telling you that he/she was constantly picking their nose and eating their boogers – in front of patients – while videotaping it for YouTube.

You won’t get fired for calling in sick. You won’t get fired for shitty patient satisfaction scores. You won’t get fired for arguing with your chief. You won’t get fired for disagreeing with patient management.

However, you could get put on a disciplinary plan if you do any of the above in excess. For example, you call in sick a lot and don’t give a good reason and don’t reach out to employee health. You keep getting poor patient complaints and resist any effort to help you improve your scores. Or perhaps you keep making repeat patient mistakes without demonstrating any improvement in your practice style. Yes, that’s happened, and yes doctors have got fired for that.

If you’re a troublemaker and worried about your standing as an employee, you have the right to request a sit-down with your chief and have her review your current standing with the medical group as an employee. They are obliged to share with you everything that’s written in your employee chart about you and they have to give you copies of it. This is great in case you are a pain in the ass and worried you’re gonna get canned soon but had a sudden Buddha awakening and now want to save earthworms and be a better employee.

Part-Time Or Full-Time

Most doctors seem to live like MTV stars so I think most will need to work full-time. However, some are frugal and don’t need the income or only need a full-time income early on in their career. The great thing about KP is that you can drop down to as little as 50% of full-time and still get all the same benefits!

So, you work 20 hours a week and you still get a 401k, you get a pension, you get a profit-sharing plan of some sort, you get healthcare, disability insurance, life insurance and whatever else is offered to the full-timers.

The only things that accrue based on your hours and aren’t equal to the full-timers are your vacation time and sick leave. Naturally, if you work less, then you will qualify for less. But shit dude, you’re working 20 hours a week, what the hell you need more vacation time for!

When in doubt, start part-time, if it’s offered, and you can always bump up to full-time later if you really enjoy the work. Alternatively, I’d tell you to start full-time and go part-time if you are feeling a little fragile, a little overwhelmed. But it’s not the same going from full-time to part-time. It has to be approved by the chief and sometimes the organization puts a moratorium on this for all departments – so choose wisely.

Cash in that sabbatical!

Did you know that more and more healthcare groups are getting rid of sabbaticals because they aren’t being utilized?! How sad. Each KP will handle the sabbatical differently but generally you get a month for each year that you work and usually you need 3-5 years to vest (before you can take the sabbatical).

For each month on an approved sabbatical you get 50% of your pay with all benefits in place. I think this is a fantastic option. There are some rules such as having to work for a few months after you come back, etc. Find out what the criteria are and follow them.

And don’t be a pushover! If your chief isn’t willing to grant your sabbatical then raise hell. Start throwing your arms around like a schizophrenic homeless person and spray urine everywhere if you have to… I don’t care what it takes, you earned it, you better cash in on it!

Get Involved And Escape Monotony

Don’t wait until you’re burnt out before taking advantage of all the amazing things KP has to offer. I’m telling you, this company is legit. You can get involved in nerdy scientific research and often you can get paid to do that.

You can become the technology guru in your department. Someone already has that title? Go after their job! Sabotage them if you have to. Download porn on their work computer and report it to their boss. I mean don’t do that shit in an evil way, you know? Maybe ask them kindly at first if they would like to give their job up to you and if they say no… well, then you are simply left with no other options.

Want to introduce innovation into your group? Maybe your department would benefit from bedside ultrasound or robotic anoscopies, whatever it might be, offer to go learn what it takes and bring that innovation to your department. There is administrative leave and pay for this sort of stuff.

Want to train with an amazing surgeon who has a unique way of managing really difficult pilonidal disease? Make the case to go study under the tutelage of that surgeon for a few months. Demonstrate how much it could help your group and you could easily be paid to go and probably land some administrative roles from it.

Follow The Chain Of COMMAND

If you are having problems with colleagues then go to that person and be genuine about the problem at hand. You’ll likely never resolve the conflict but at least you’ll take the edge off of it.

If that fails then go to your PIC and review the problem. Meet with them again and if you truly cannot get anywhere with the problem at hand then let them know that you’d like to talk to the chief about it as well.

Meet with the chief and be direct about what your expectations are. Be fair and spend the effort of going back and forth. If you don’t and later lose your shit then you’ll be the one that looks incompetent.

If needed escalate it from there. Again, always stay respectful, always stay open but be honest. It’s not your job to let them know “how” to get something done. Your job is to let them know what is and isn’t working for you. Sure, you can make suggestions but don’t put it all on your plate.

Ask For A Raise

I mentioned above that KP’s physician compensation model is a closed system. Nobody gets paid disproportionately to another physician. If you are getting paid more than someone else it’s because you are in a predictably higher tier. KP won’t pay you because you are higher performing.

If you want to earn more money, first make sure that you are deserving of it. If you go to your boss asking for more money then hopefully they already know without you having to tell them that you are in the 90th percentile of overall performance.

The first thing they will tell you is that “but we can’t pay you more, everyone gets paid based on a specific scale”. Great, you aren’t asking for the scale to be adjusted. You simply would like to get paid for some non-clinical time, however that might look. Now you and your chief are speaking the same language. As to how it’s accomplished, that’s for them to figure out and as I mentioned, if you have the value then they will work with you.

If You’re Good But Unhappy Let Your Chief Know Early

If you suck as a clinician and you’re unhappy, I doubt anyone will go out of their way to do anything for you. I suppose that’s the nature of a large medical group. They might even show you the door if you complain too much.

But if you are a competent clinician and get along well with most of your colleagues then go to your chief as soon as you start feeling overwhelmed or just feel undervalued. I know it might seem weird to do so but I think it’s critical. The organization values their competent doctors and does whatever possible to keep them happy. I told you what unique options are available above so perhaps a combination of that might be applied to your case to make you happy again.

 

Take Time Off, Resume At An Older Age

If you can ‘retire from KP‘, meaning that you spent enough years to vest in your retirement plans and have been there for at least 15 years, then you get the option to come back as a preferred per diem and earn the same hourly wage you got when you were full-time.

There are certain criteria you have to meet, one of them is having worked at KP long enough. Next, you have to be past age 55. You also have to be in good standing. Punched your chief in the face a few times? That might hurt your chances.

Currently, as a Family Medicine physician, I get $100/hour as a per diem. However, if I was 55, I’d likely be making closer to $150/hour. Being able to work in retirement for more money is a brilliant opportunity.

So, I am arguing for you to consider taking some time off from work, perhaps between ages 40-50. You can still work part-time or per diem to earn enough to live off of. But you can then come back from age 50-55 and complete your minimum requirements and hopefully be invited back to work per diem as a retiree.

This is especially helpful for most docs who start burning out in their late 30’s. A little change like this could be all you need to keep you from cutting your wrists or verbally abusing your dog.

 

The Downsides Of Kaiser Permanente

I was warned by my program director to “never work for an HMO”, I am really glad I didn’t listen to her. I realize that some HMO’s are pieces of shit and all about the dollar. Perhaps I am brainwashed by KP but I never got that sense that they put profits over patients.

With everything I’ve said I also need to tell you that I got majorly fucked over by Kaiser Permanente as a physician after I became a per diem. I have written a lot on this blog about the incidence and the only reason I’m okay with it is because I milked Kaiser for far more than they got from me and at 38 years of age I retired from KP.

No Shotgun Medicine

Kaiser is a minimalist model. Even though they have some of the smartest specialists I know, some of the best technology around and access to damn near any resource, the point isn’t for you to go there to practice shotgun medicine. It defeats the purpose of being an HMO.

So one downside to KP is that you can’t go there to practice traditional US medicine. Though nobody will give you shit for ordering numerous MRI’s or viral cultures on every oropharyngeal swab, they will recognize you as being a high utilizer and will offer you feedback on this. If you can justify that those tests are necessary, that’ll be the end of the conversation.

Bosses, Managers, Supervisors

There is so much local leadership that your head will spin. You have to go to one person to discuss a paycheck problem, go to another person to discuss a scheduling issue, another for benefits, another for a problem with a colleague.

I wish I could say that each department has competent employees, however I haven’t found that to be the case. In my years of picking up extra shifts at SCPMG, every other paycheck was short some hours. This isn’t an exaggeration.

Compartmentalization allows for more efficient management by each group. They can master their skills and not get spread too thin. However, it means that you really need to figure out the KP system. Once you do, you are good to go and you’ll be running on water.

The Goddamn Union

Everyone is in a union – well, except the doctors. When it comes to making global changes, there first has to be some union negotiations. Even though you’ll adopt the change readily, you might be scratching your head wondering why the fuck things aren’t happening faster.

I guess unions are good. I am all for doing the least minimum to keep your job. This is ‘merica!

You Are As Good As Your Paycheck

Nobody gives a shit if you have better patient outcomes, shorter patient wait times, utilize fewer resources, have fewer bouncebacks, better patient satisfaction scores or see far more patients than your colleagues.

As a matter of fact, if you perform really efficiently, you’re going to get more work dumped on you. The faster clinicians will get more patients and the more competent clinicians will get the tougher patients.

So, you are as good as your paycheck. What do they call the medical student who performed the lowest in their class? A doctor. In the end, you are an employee. Though you might be able to get away with a few more shenanigans if you are in the elite tier, you won’t get a higher salary, you won’t get more vacation time, and you won’t get extra leniency when making mistakes.

My advice, work only as hard as you want to for your own satisfaction. Ideally, try to perform just under the median. The less you do, the less will be expected of you. You can see 50 patients during an urgent care shift or you can see 21 – same pay, less work, less risk, more time to document.

 

Contract NEGOTIATION

It’s said that you can’t negotiate your contract with Kaiser Permanente and other similar large, established medical groups who pay their physicians equitably. This is false. I know this firsthand because I negotiated my own $20k raise the second time I got hired by KP.

There is some truth. Certain things are written in stone and it would require the board’s approval to make a change and they only meet a few times a year. But there are plenty of bonuses and stipends and pay scales that can be negotiated.

Way more important than negotiating a higher salary is just understanding all the benefits that are available to you. If someone who is competent can review your employee handbook and your benefits packages along with your employee contract, that’s worth $5,000. When in fact, you’ll rarely pay more than $500 for a contract review.

 

If you are looking for more information you can schedule a call with me through calrity.fm. This is a paid service that I offer and I’m sure that I can add more value to you than what you’ll pay for this call.


20 Comments

  1. bill

    Happy to have read this. Very interesting, although I retired from NCAL (no sabbaticals up here).

  2. Thanks for posting here. Would love to chat with you and maybe record a podcast episode for others to hear what your experience has been both as a retired physician and someone who worked and survived Kaiser.

  3. samgakjiyeok

    This info is gold. I can personally attest to the ramifications of yelling at a incompetent nurse (just twice) while working at LAMC sunset urgent care. They don’t F*ck around. I was placed on special category as an associate. I quit after I got burnt out and doing per diem for 2 years. I am trying to negotiate a kaiser part-time 5/10s gig. It’s interesting how you mentioned negotiating. I might be calling you for some consultation in regards to this.

  4. You should consult me 🙂 your money will be put to great use! go clarity.fm/drmo and book it. I just helped a specialist who was transitioning to KP secure a higher income with some negotiations. It’s doable and honestly you can probably manage it yourself without my input. The key is to understand that they need you and you need to know what options they have available to them. They need to make it worth their while because it’s more expensive having a part time doctor than a full time doctor. But each department measures their access and reports that to Oakland. So you need to fit into that puzzle somehow. Good luck homy!

  5. Anonymous

    I am a respiratory therapist., wife’s an RN, some of our doctor friends, we think do very in that compensation cartegory. Kaiser pays us pretty good also. Everything you said is so f-ing true, don’t fight the organization, well said.

  6. As an RT and RN I’m sure you guys are doing quite well for yourselves. I have some incredibly wealthy and financially successful RT and RN friends from back in Cali. The overtime and overnight shifts aren’t easy but the pay differential can be very lucrative. Especially if you can stay out of the office politics you can do very well for yourself. Few understand the incredible opportunities of being an RT. Would love to hear more about your guys’ lives.

  7. Anonymous

    Unhelpful article. Are you really a kaiser physician ?

  8. As opposed to … undercover Providence Medical Group or a PPO competitor?

  9. Anonymous

    This comes across like it is written by a typical physician douche bag. It’s really unfortunate that it seems like the rule and not the exception that physicians truly only care about themselves and are not truly a part of the “team”.

  10. As physicians it’s important to protect your career because nobody else will. The medical boards and lawyers aren’t there to uncover the truth, they aren’t there to help you become a better physician, they are out to get you. This is not a sensationalist statement, it’s the narrative of many physician careers.
    KP will eat you up and spit you out the moment you are no longer of value to them. And from this commentary you can see how people react to a physician who might stand up for themselves. This same person will be who will be on the jury when that time comes to have to defend our careers.
    But in the end, even these ill-wishing individuals want nothing more than a caring physician who will make their clinical decisions independent of any biases built into the medical system. How do you achieve that? You have to look out for yourself and your career. Before you can make independent clinical decisions, which might get you into some hot water, you have to break free from the financial constraints of the medical system. What’s the best way to enslave a physician and indoctrinate them? Put them under a burden of debt at a time in their life when they would want to start a family. Next, limit their ability for critical thinking and off-label use of treatments.
    The few physician readers of this website know that this is a recipe for disaster both in terms of career satisfaction and the greater good of society.

  11. Looking

    Currently trying to negotiate a contract in NoCal, i here there’s no sabbatical although it’s better working here than so cal.
    Wondering if a sabbatical can be worked into my contract. Do they hire directly for urgent care or do you have to go through PC first?

  12. Norcal has its own UC department so you’d get hired through them and not PC.
    I don’t think you can work in a sabbatical. I don’t even recommend a sabbatical with KP. It’s far better to take unpaid leave or bank vacation time.

  13. Anonymous

    Cannot be rehired in MAPMG. If you retire from MAPMG you are required to take the ‘supplemental distribution.’ That is, MAPMG pays you the difference between the maximum federal determined salary and what you were actually earning. THIS DISQUALIFIES YOU FROM FUTURE EMPLOYMENT AS A SHAREHOLDING PHYSICIAN. You are not give a choice about taking the supplemental pension distribution. So, think carefully before leaving. In the old days, TPMG would allow physicians to resume as shareholder track. No more.

  14. I believe that is likely true in regards to returning as a partner but you should be able to get hired on as a per diem at any time. The difficulty might be that they might have to hire you as a per diem and pay you a partnership rate. That’s why, if you do decide to leave, it would be good to transition down to a per diem position first before leaving. This will make it easier for you to later return as a per diem. Then again … why return back to KP after breaking those handcuffs and taking out the gagball and the… well, you know. So many other great opportunities out there.

  15. Anonymous

    Physicians have taken the Hippocratic oath to “do no harm”. With that said, I have noticed more complacency as the older generation retires compared to the newer physicians in practice (5 plus years).. If you are not happy, find another career. Yes, physicians all deserve to make a living with benefits, etc., Whatever happened to treating patients with dignity, compassion and giving them first class service to resolve their health issues?

  16. Society will always have expectations from physicians. They are often held to a higher moral standard and treated as gods. The oath we have taken, what we owe patients, the “healing” we’re responsible for … all this adds a lot of burden to our shoulders as physicians. In return we are told that the high income we earn should be more than adequate for our compensation. But we didn’t go into medicine for the money. We didn’t go into medicine to be sued by patients who didn’t like their outcome or have patients demand pain medications or antibiotics and then file online complaints about us when they don’t get what they want.
    The people who tell physicians to go find another career if they’re not happy often have never sacrificed 10+ years and went into $200k+ student loan debt to get a career and so it’s quite easy for the rest of the world to want to police us.
    That said, as soon as someone refunds me my student loan money and resets my career clock, I’m happy to pursue another career.

  17. Anonymous

    Dr Mo, you’re awesome! I love how you respond to everyone with honesty and respect, despite the fact that some of these comments are so rude. You are absolutely right that physicians must look out for themselves first. Of course, this does not mean compromising patient safety. In fact, looking out for yourself as a physician means prioritizing patient safety, but unfortunately, administration does not always agree with us. There are so many things that we feel ethically obligated to do but end up having our hands tied by administration. I don’t think most patients will ever understand this dilemma. Also, in regards to compensation, the compensation that we get is not just for ourselves. Many of our families depend on us. This can include extended family. I would also love to turn back the clock on my career. I love my job, but I think I would love another career better. It’s so sad to say because the only thing that makes me say it is all of the unavoidable politics. So many doctors told me not to go into medicine, I didn’t understand what they meant… until now.

  18. Thank you for your kind words. Patients want good quality care from their doctors and doctors want to offer good quality care – thank dog we are all on the same page when it comes to healthcare. But totally agree with you that we are getting hamstrung. There is no “they” who will turn things around for us and the average healthcare consumer cannot differentiate between good and bad health delivery. But fortunately we have options as physicians, even though most of us would prefer to collect that juicy $20k/month paycheck. I don’t think we need to boycott large medical groups or flee as employees. Instead, build something else on the side, have an escape. Then start offering positive but forceful feedback to your employers and let them know that you’ll see however many patients that you feel allows you to practice good medicine. That you won’t prescribe opioids just because the patient is already on them. That you won’t skip the MRI just because the RUAT team wants you to order a shitty CT non-contrast first. And, of course, have all your FMLA and disability and wrongful termination arsenal locked and loaded because when you give pushback, you just may have to resort to some ugly tactics. Fortunately, I have all of that outlined for you guys here as well. We might be lovely and sweet in the exam room with patients but don’t fuck with our careers because we’re smarter than HR, admin, and management – we can fight dirty too.

  19. Linda Tieman

    an interesting piece you wrote. The docs at KP are essentially their own “Union” despite what you say. The Perm group is for-profit, unlike the rest of KP, controls its membership, and negotiates for its “Income” from the larger org annually. No system is perfect, for sure. The information system within Kaiser is stunning for both patients and providers. I have been a member for many years in more than one region. At least there appears to be some interest in accountability which I’ve not found in fee-for-service healthcare.

  20. As a former partner at KP I wouldn’t compare it to a union but it is the largest physician group in the US most likely and so they have a a lot of negotiation power. But because all of the benefits and office space and malpractice comes from the other side, there isn’t as much negotiation power as you might think.
    As for quality and accountability, your definition of health might be different from mine. My definition of quality of life and how relates to longevity will likely differ from yours. I therefore can’t make any generalization about Kaiser. However, if I had cancer, for example, and wanted to have the highest chance of survival, I would probably do the opposite of what Kaiser says. And that’s been proven anecdotally bt my own colleagues who’ve had parents with cancer at KP.

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