A conversation with Dr. Jeff Williams: neuroradiologist, practice president, and twenty-year veteran of the hiring side.
Two physicians can generate the exact same revenue and take home wildly different pay. When I asked Jeff Williams why, he didn't hesitate: it's structure, and almost nobody asks about it.
"Residents and fellows need to understand the capital structure of the practice," he told me. "It's the thing they never think to raise."
He laid out the categories like a man who's watched people sign without knowing which one they were in.
"Am I joining a private-equity-backed practice? A vertically integrated health system run by a payer - Optum, United? Is this physician-owned and operated? Is there equity? Is there equity I'm buying into?" Each answer, he said, rewrites your compensation, your autonomy, and your whole trajectory.
And he's the first to say the ignorance isn't the resident's fault: "No fault of their own; I was there. You don't even know what to ask."
Then he made it concrete, in dollars.
"Every Vanderbilt doctor knows they're tithing the mothership," he said - a cut flows up the chain, and everyone understands the deal. "But if you're joining a big multispecialty group, you might not understand that you're getting only 75% of your collections, and then you have overhead, and then you're paying three-and-a-half to four percent of your profit to the parent company." Nobody lies to you. Nobody draws you the org chart either. "That's usually where things start breaking down."
So he wants candidates asking the money questions out loud. Is there equity, and what does buying in cost?
"We wouldn't necessarily want to tell you how much it costs to buy in," he admitted of his own practice - "but we'd say, you can have an ownership stake in the outpatient imaging, you can buy into our billing company."
The point isn't that every group hands you equity; it's that "they have to understand where the money is going." A practice proud of its structure will walk you through it. One that won't has told you something, too.
He ticks through the pay structures the way a cardiologist reads a rhythm strip.
"Is it a guaranteed salary for two years and then I'm paid on a percentage of collections? Am I paid on an RVU basis? By CPTs?" The same headline number, he warned, can mean a radically different paycheck once the guarantee quietly expires, which is exactly why the structure matters more than the figure that's designed to catch your eye.
He offered two tells to watch on the way.
The first is the offer that glitters too hard. "If it looks too good to be true, it is," he said. "They're probably paying you 1.5x to live somewhere remote, and you're going to be taking call every other week. There's usually a reason."
The second is turnover - and he described the death spiral precisely: "A lot of practices, as they start to go into it, have massive rapid turnover, and salaries start going up." A rising number isn't always generosity. Sometimes it's the sound of a back door that won't stay shut.
What surprised me most was Williams insisting the misalignment is expensive for the employer, too…which is exactly why your hard questions shouldn't scare a good one.
"They'll prop up a new rockstar doctor," he said, "and then within six months there are problems, and they quietly shuffle them out the door. You've lost a million and a half, two million dollars in lost revenue and recruiting."
And yet, he said, plenty of groups are in denial about it: "They'll tell you, 'we don't have a hiring problem, we pick who we want' - and I know they're struggling to keep people. Where's the disconnect?"
His answer is the one number most practices won't volunteer.
"You want to ask: when was the last person you hired? How many have left in the last year, and why?" If they won't answer, "that's immediately a trust bond you're never forming."
He's convinced the honest practices would happily hand this over, that the disclosure itself is a selling point.
"A smart practice would tell you and tout it," he said. His own move was to volunteer it: "People come to us and they stay. We've had three people leave in the last two years, and these are the reasons why."
The tell, then, isn't a high number so much as a refusal to give you one. "If somebody's not willing to provide absolute disclosure," he said, "that's immediately a trust bond you're never forming. You'll leave the interview thinking…gosh, they let me talk to one guy, but they didn't answer my question."
Williams's bottom line is the kind of thing you'd expect from someone who's signed the checks and read the fine print for two decades. You wouldn't prescribe a drug without understanding its mechanism. Don't sign a contract without understanding where the money goes, and who's keeping the part that isn't reaching you.