The Lucrative Side Hustles of a 7-Figure Urologist

Early in 2019, we heard the origin story of a 7-figure urologist. In that post, he focused on his upbringing, his education, and the way he has structured his practice.

He returns with a detailed description of how he has benefited from a number of lucrative “side hustles” that have resulted from both his position as a physician and his ingenuity and willingness to take risks.

All combined, his side gig money adds up to more than the annual salary of most practicing physicians. If you feel that it’s more valuable to be a business or property owner than an employee of one, you would be correct.

While not all of these opportunities will be available to you, don’t write these ideas off as completely out of reach. It’s more about the mindset. Most income streams like these don’t fall into your lap; you have to create them.

 

side hustle urologist

 

The Lucrative Side Hustles of a 7-Figure Urologist

 

Coming out of residency, I wanted to maximize my earning potential. I analyzed ways to augment my earning potential as physician. I did spend almost $300,000 on my education at this point and was looking for a solid return on investment.

I will mention several field-specific ventures but hopefully as physicians, it can inspire some outside the box thinking in your individual fields.

 

The Surgery Center

 

This venture taught me a lot about how physicians think about money. We have a joint venture between the hospital and staff at the surgery center. This is entirely attached to the hospital and a unique venture, especially for my rural hospital.

The hospital owns 21 shares and there are 19 shares available to the physicians. Share prices started at $55,000 when I finished residency and are currently selling for around $65,000. I started by buying one share right out of residency.

Over the course of the last 6 years, I have been able to increase my shares to 5.5. The annual dividend for this venture ranges between $18,000 to $23,000 per share. So even on the low end, it earns about 30% return annually.

We have several physicians who have had a chance to buy shares and some choose not to. I am the president, and we currently have 1.25 shares available. My CEO kindly asked me not to purchase any more shares. Otherwise, I would definitely purchase them.

I was able to use my bank to 100% finance this venture and the dividends more than pay for the note. The current value of my shares is about $350,000. I owe $190,000 on the note, and my dividends are right around $100,000 per year. My basis in the project is about $320,000. The hospital backs a buyout with 30-day notice. Not the most liquid asset, but money can be out within a month.

 

The Medical Office Building

 

I made this investment when I was in my second year of residency. My hospital has a 20,000 square foot medical office building (MOB) that is attached and physician-owned.

Yes, I built my urology office as a resident. A daunting task at the time but with a little research worked out very well as I am still practicing in my office and I wouldn’t change a thing.

The building is set up as an LLC. Ownership is based on how much of the space you lease compared to the available space. The hospital leases about 60% of the space with no ownership interest. The initial investment was $65,000 which I paid off over 7 years again with a 100% financing option.

The dividends on this investment average about $7,500 per quarter. The building will be paid off in about 9 years. When the building is paid off, the net dividends will nearly triple as there will no longer be a mortgage payment.

 

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I also built my wife’s dental office in the same building. This gives us about 15% ownership in the building. The building value when fully occupied and with ten-year leases in place has a value of about $9 million.

Side note, my accountant at the time of building the suite during my residency advised me not to do the deal. He claimed I would make all my money practicing medicine.

I went ahead with the deal and fired the accountant.

 

 

 

The Lithotripsy Machine

 

I knew that Urologists usually owned their own lithotripter and I wanted to find the best deal out there. Lithotripsy is actually a fascinating legal case study. It was well fought to keep it from being a designated health service under Stark and anti-kickback laws.

I started out with the intention just to buy my own machine and just rent it to the hospital where I practiced. Seemed easy, but the initial investment is about $650,000 and a bit daunting in setup.

In my exploration, I took several reps out to dinner to start to get the lay of the land. Several reps mentioned one company that was opposite of the normal Ponzi schemes I was used to reading about. This group retained 20% ownership and gave the rest to the physician owners.

As a chief resident, I was able to organize a new lithotripsy group with 6 other docs. Our initial investment was $23,000 each. Our average dividend over the life of the venture, now about 6 years is $6,700 per month.

We are now at 11 docs and share prices are around $100,000 to buy in. We just added a second set of equipment. There are about 60 of these partnerships around the country and mine is the only that I’m aware of to be formed by a chief resident.

 

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Additional Clinical Positions

 

I knew early on in my career that I perceived great success from being busy as a physician. My job did keep me busy for the first year, but then I felt I could branch out.

Urology is very limited by the amount of docs finishing residency each year, so there is tremendous demand. I practice about 25 minutes from where I live and the local hospital has been very pesky in asking me to cover for them.

The CEO of the hospital is my neighbor and he gave me tremendous amount of grief as to why I wasn’t involved in caring for the community in which I lived. I ended up caving for weekend call coverage.

I was able to negotiate $2,000 for a weekend starting Friday at 3pm and ending Monday 6AM. I also get $250 per consult and $400 per case. I also get extra pay for holidays. This nets me additional income of $50,000 to $60,000 per year.

I also have started a practice in another small town 25 minutes from home. This job is shared with another urologist. We cover every other Friday and call for the month. This position pays $350 per hour and $500 per month for call pay.

My advanced practice registered nurse is also involved here and makes $100 per hour. This venture nets me $12,000 to $15,000 per month. I see this growing in the near future as I am hiring additional advanced practice providers. This is also where my private practice still exists and has several tax advantages such as cash balance and profit sharing plans.

These side hustles net me about $400,000 to $500,000 more per year than my full-time gig.

 

[PoF: I want to thank today’s guest author for his willingness to share the many ways he has found to supplement his physician income. As hospital and corporate medicine employment becomes a more common practice model for physicians, there are fewer physicians flexing their entrepreneurial muscles. As the urologist shows us, ample opportunity still remains.]

 

 

What are your medical side hustles? Are you earning passive income from prior investments in a surgery center, medical office building, or medical equipment?

20 comments

  • Absolutely incredible and quite mind blowing on some of the things you did in residency while most of us are just trying to get through training.

    Definitely was a risky proposition to buy a building (or even organize the lithotripsy buying group) as you essentially committed yourself to working in the area (risk would be minimized if you knew you had a position waiting for you on graduation and you had strong ties to the region anyway and would not have left).

    My biggest grand slam of an investment was my medical office building. Got in on the ground floor in 2006 and it just got sold this year. The original shares I bought were worth 23x more and because I bought every share that was subsequently offered through the years my blended average was close to 15.5x my basis (this is going to make for an eye popping capital gains tax hit for my return this year).

    Like your experience, not every physician jumped at the opportunity that presented itself and thus gave up on the subsequent large reward (I had to take out a bank loan to buy my original shares as I just started practicing here when the investment opportunity came).

    • Tom Zaciewski

      I think this is another example of being exposed to an excellent investment opportunity due to your physician status. These opportunities should all be evaluated. Anytime you can be your own tenant in a real estate situation it tends to be a good deal. I had a position locked down in the town before I built out the office. My wife also had a dental practice established in the building while I was in residency. This is about an hour from where I lived in residency and 20 minutes from my in laws.

      TZ

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  • Roundabout

    Great to see other business-minded docs thrive in the current environment. Eerily similar to the situation here, with revenue from surgery center shares and one other ancillary business now exceeding income from medical practice every year. I would have never imagined that to be the case ten or fifteen years ago. Has greatly accelerated FI path, but a bit of the “golden handcuffs” situation in play. Thanks for sharing your story.

    • 7-Fig GU

      My situation is also dicatated by the hospital with the building for sure. We did attempt to place the building up for sale and had several interested REITs. Our hospital administration vowed to pull the leases if we sold. Se we just have to sit back and collect dividends. After the building is paid off in ten years, the dividends will be in 100k range each for my wife and my self at current rental rates and our equity stake will be 7 figures.

  • nightnightdoc

    My question is how to find these opportunities. I would the opportunities to buy shares in a surgery center, etc. Who do you typically reach out to? Perhaps the investment opportunities are not common, but where do you recommend starting? Thank you!

    • Tom Zaciewski

      These types of investments are usually in plae in most regions. If a surgery center does not exist in your location, you can reach out to other docs and try to form one. This would be a big undertaking but worth it for long term wealth. Certain specialties are more lucrative in this setting, GU/ ORTHO/ Optho/ ENDO. There are companies out there that specialize in putting together surgery centers for docs. They will take a pound of flesh for their services though. I am always happy to discuss opportunities

  • adicksurgeon

    heh, I’m just a 2nd year urologist still trying to clamp down on that slippery vas deferens. I also read your origin story judging from the date you would have finished residency around 10 years ago. Would you say that current regulation is stricter with medical offices and lithotripsy ownership?

    Just out of curiosity why are you going back to the private sector? Kaiser (golden handcuffs) seems like a pretty good gig for employed physicians (albeit the many cons)
    Lastly, in your current thoughts do you feel that urology is heading towards the orthopedic model where fellowship makes you more competitive and have more leverage with career opportunities?
    PS would also like to view an article on negotiating and leverage.

    • Tom Zaciewski

      First off, I finished residency 6 years ago. I think that real estate values in general have increased significantly recently which make some of the real estate ventures bigger financial commitments. Litho ownership remains the same. It is not considered a designated health service for stark and anti-kickback laws. As chief resident I felt that most litho options were ponzi structures for the old guys. This is why I started my own group. I am heading back into the private sector mainly because of how I am compensated for my APP’s. I had a situation last year where I was above the 75th percentile for dollar/RVU and had a 6-figure bonus withheld from me. I ma heading back private but under a professional services agreement (PSA). I feel this model offers me flexibility on my comp but the hospital still handles billing. I just have to handle my own malpractice and health insurance but get a n $/RVU bump to cover these. This gets me out from underneath the microscope of the regulations. This kind of structure will probably be in another post. I am not sure about fellowships. I feel that fellowships are mainly for the propagation of academia and are not pragmatic. I really hope we do not reach the ortho point but with more programs now at 5 yrs instead of 6 the fellowships will probably increase.

      TZ

  • Examples like these are helpful to show the way.
    I used many of these same methods to build wealth.
    There is more to doctor money than just your W-2 and a corporate paycheck.

    • 7-Fig GU

      Thanks for the encouragement. I agree on the w-2 thing. Just maximize the amount of money made during the time spent away from family.

      7-Fig GU

  • Wow! Incredible, sounds like he has done incredibly well! I personally would be a bit concerned about concentration risk and maybe look into diversifying in investments outside Medicine as well if he hasn’t already

    • Tom Zaciewski

      I don’t feel as if I am very concentrated in investments. These are just the ways that I have maximized my physician earning potential. I have large retirement and non-retirement accounts. I also own residential and commercial real estate. I have a nutraceutical start-up company and own seven restaurants. The article was to inspire docs to consider how they can maximize the dollars earned when practicing medicine.

      TZ

  • Mark Holbrook

    Could you follow up this article with one about how you handle your tax situation? Or maybe just provide ideas on how to minimize taxes given you investment income. We all know the basics (IRA, Roth, etc..) but I am looking more at maximizing depreciation or other ideas?

    • 7-Fig GU

      The Tax game is a constant in my life. It’s not how much you make but how much you keep. I do keep a portion of my practice as private so that i am able to write off several day to day expenses as business expenses that i would not be allowed to if i were completely employed. Just pulling things out of your day to day budget such as car payments, gas, insurance, cell phone bills, home internet, and uniforms. This adds up to several thousand per year. You have to watch some tax plays such as depreciation. This a “kick the can down the road” strategy. I have several businesses to help offset some income as well. I also utilize a cash balance and profit sharing plan for retirement from the private business. I am currently the only employee so can make 6 figure deposits annually in addition to 401k and 457. I have two off beat tax plays that i made.
      1. I bought a building at auction, remodeled it, donated it to the local chamber of commerce, wrote off some of the rent for 5 years. I sold the building for what i had into it but made three times that back on tax savings over the past 5 years.

      2. I have a group that sponsored an archeological dig through a college. We paid for the dig and get to keep the 70% complete triceratops they found, including the skull. We mounted the bones and then donated it to middle school for the lobby in their new school. We get to write off the value of the dinosaur. We are all 7 figure guys so the tax savings will be about an 8X from the investment. it did take three years to complete. I included a link of the dino, https://mobile.twitter.com/cvbuckskins/status/1144269487543398405. My kids definitely think this is my coolest investment/ tax play.

      Overall it is just something that needs to be constantly minded.

      • Mark Holbrook

        Definitely going to look into a cash balance and profit sharing plan, but we do employee a doc and to three midlevels.

        How can I learn more about the building tax play? I like getting involved in real estate and it seems like a worth while cause. The Dino dig is just so cool it is completely out of my league!

        Thanks,
        Mark

        • 7-Fig GU

          The building deal came about by chance. It did take my accountant and an attorney to work up the documents. The cash balance and profit share plans will come with some fees but it more than pays for it self. You will have to weight the costs of contributing to the employees but if they are great providers then it is just another way to incentivize them. The dino deal is hilarious to most people i tell. I did send a few large checks to a motel in South Dakota which was a bit sketchy but it all worked out in the end.

  • Ether to FI

    Sitting at work on a Saturday and reading this article just reminds me there are more efficient ways to make a buck. Once again inspired to be an owner and not just an employee. Thanks for sharing, you are my reminder to get a move on.

  • GURU

    Practicing urologist here: I’m currently in a lithotripsy group and we average monthly dividends around $6500.

    I’m curious as to your comments about Ponzi scheme litho groups and ‘benefiting the old guys.’ I’m not an old guy <5 years out from residency. Can you give more details about what you mean?

    • 7-Fig GU

      One of the litho groups i looked at had several urologists from multiple areas that all went into one company. the guys that were there for the longest time owned several shares. new guys coming on could only ever have one share and the cost of the one share was higher than the older guys paid for several shares. There are some FMV regulations that come into play here. I just found it was better to have a smaller group of like minded guys and where no body gets taken advantage of. Our new guys buying in are at around 100k per share which is a lot more than i paid but dividends are a lot higher now and cash is flowing as soon a you sign, all members get equal monthly pay out. all guys can have only one share. Some days i wish i would have just bought my own machine/ C-arm.

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