The practice primer

THE WORLD IS YOUR OYSTER. WHEN YOU COME TO A ROADBLOCK, TAKE A DETOUR. Believe you can have it, believe you deserve it, and believe it’s possible for you. Don’t worry, be happy. Yes, job searching is full of inspirational pats on the back and locker room speeches.

Unfortunately, for many physicians, that’s the sum of the advice they seek out during their job hunt, says Gregory Buford, MD, a board-certified plastic surgeon in the Denver area. “A lot of physicians get caught up in their own arena and get walled off. They expect they know something about everything and they need to put the ego down and ask colleagues what they like, what they don’t like, and find out what practice model fits them,” he says. “In reality, in medicine we’re running a business.”

As this need to take a business angle takes more of a center stage in American health care, physicians need to interview for opportunities with an eye toward a good match with not just their lifestyle and income expectations, but personality, too. Here is a rundown on the common set-ups and what it takes to be successful within those boundaries today:

Solo practice and partnership

PROS: “Doctors working without partners can make business changes literally overnight,” says Judy Bee, a management consultant at Practice Performance Group in La Jolla, California. “When I tell a group they need to open at 7 a.m. some mornings, they have to hold a committee meeting, decide who will cover the new shift and in the meantime, nothing happens,” she says. Such nimbleness naturally ditches politics and their headaches in the process.

CONS: A successful solo practitioner needs to have a bent for one-on-one marketing, which includes personal touches like thank-you notes for new patients, community participation in pancake breakfasts, and social media updates. Primary care practices in particular are built on word-of-mouth.

FINANCIAL CONSIDERATIONS: Because well-run solo practices are efficient machines, it’s almost always possible to bring overhead below the percentage a group pays. Because they rarely can afford a lab or other ancillaries a larger practice offers, the actual dollar amount solos earn is less, but the percentage of receivables is higher.

On the other hand, Bee saw her first solo practice bankruptcy in 30 years of coaching in this recession. “The predictions you make for income may be completely skewed from what others have said happened to them even a couple of years ago,” she says. “We’re making sure physicians have very realistic to conservative projections and that their war chests or personal funds are well intact for a solo practice because they may have to draw on these funds for quite some time.”

BEST FITS: An activist with an entrepreneurial knack and risk-takers who are comfortable looking in the mirror and saying, “You blew that one” because there’s nobody else to blame in this model.

THE REAL WORLD: “It’s better to work somewhere else for a couple of years because when you’re fresh out of training, you’re slow as molasses in seeing patients,” Bee says. “A big day in the residency program might be 10 patients, and you’d starve to death on that solo.” Ramon Resa, MD, didn’t heed that advice in the least when he left his residency in 1985. He moved near his home area to start a solo pediatrics practice from the beginning. “I’m not keen on authority, I don’t follow instructions, and I don’t follow protocols,” he says. “If I worked for a clinic or big institution, I would be butting heads with people because I like efficiency.”

For the past 20 years, he’s offered 24/7 coverage, setting specific hours to return calls over nights, weekends, and holidays, and accepting emergency calls on the spot. It sounds stifling, but Resa insists patients today are respectful of his time and usually seek out 24-hour urgent care. Not a soul called to interrupt this Thanksgiving in 2009. Still, Resa “didn’t have a clue” about the business side and credits his survival to hiring a good office manager to handle billing, insurance claims, and corporation decisions. “We’re going into electronic records now—I don’t have time to handle those negotiations,” he says.

The profit and loss statements have become so dicey, however, that Resa cautions against solo practices these days. His own plan is to scale back to a concierge, cash-based model after his kids are through college. “I don’t need the money—it’s about providing the services. I want to be able to enjoy medicine again just for the sake of medicine instead of dealing with the headaches that go with it,” he says.

Single specialty practice

PROS: Bee always recommends physicians work within a single specialty group as opposed to a multispecialty model because overhead percentage is typically lower (think purchasing power) and the personal turmoil within the practice is less since partners aren’t trying to keep specialists happy at the expense of primary care providers. (Bee believes six is the ideal number of partners in a single specialty.) Physicians themselves say the camaraderie is helpful to their careers, and such support can allow them to stretch their wings into new techniques and approaches.

“If we weren’t in the same office, we’d compete with each other. That’s the bottom line,” says plastic surgeon Greg Buford. “We might as well join forces to optimize our revenues and gain all the benefits.”

CONS: Without additional specialties under the same umbrella, you limit patient referrals.

FINANCIAL CONSIDERATIONS: The lack of variety also narrows some ancillary income streams. Adding an endoscopic lab to a GI practice, for instance, brings additional fees but also staff to operate it. “If you don’t have enough volume you still have that overhead,” Bee says. Doctors in single specialty models need to expect fluctuations in their income throughout the year.

BEST FITS: Incredibly good listeners with a variety of communication styles to influence their colleagues.

THE REAL WORLD: When Buford joined the other two plastic surgeons at the Center for Plastic and Esthetic Surgery in 2000, they had a typical all-for-one and one-for-all mentality. “We felt we needed a united front: we needed to advertise together. We needed the same look,” he says. “Well, good luck getting two plastic surgeons in a room to agree on anything.”

When the time came to replace a departing partner, Buford jumped in with his idea: Allow each surgeon to build his individual brand, essentially a solo practice within a group. It certainly made sense for Buford, who was into doing media interviews and appearances for his breast augmentation niche and likes to team up with non-profit organizations on projects that didn’t mesh with his partners’ niches. Today, each surgeon receives a set salary from the shared income, and the group divides fixed expenses equally (think rent, utility bills, an esthetician’s salary).

They are then given a pot of money to direct as they see fit. Buford spends his on marketing. Funds available beyond this are bonuses paid out every quarter according to productivity. Each surgeon gives patients his cell number for offhour questions, and if the surgeon is out of the office, a partner steps up to cover any emergencies. The model feeds Buford’s business acumen, he says, as well as his expectations of customer service he came to expect growing up in the Pacific Northwest, home to such retail giants as Nordstrom’s and Starbucks. “I would say to anyone going into this practice type to read a good marketing book at least every month,” he says.

Multispecialty group practice

PROS: Combining symbiotic specialties with primary care at the core can expand patient referrals. Patient satisfaction ratings are higher, as whole patient care improves. Like a single-specialty model, the purchasing power is also greater.

CONS: Specialty physicians hungrier for greater traffic flow will have a difficult time finding referrals from the community, as primary care doctors in particular don’t want to send their patients into a corporation with its own primary care doctors. Personality clashes are more likely when specialties mix, and the contracts can be very tough on non-compete issues.

FINANCIAL CONSIDERATIONS: Look at the ancillary income. If the cost to operate labs and other services is draining the overall profits, your piece of the pie may be smaller even when your volume is up. Check whether the insurance plans in the area have contracts with other labs, which would cut the group out of this opportunity even with its own patients. Finally, ask about the turnover rates. If the high-end specialists leave often, it signals income instability for you.

BEST FITS: Incredibly good listeners with a variety of communication styles to influence their colleagues, people willing to compromise for the good of the group.

THE REAL WORLD: Neurosurgeon Sumeer Sathi, MD, tried the single specialty route on his first career stop, but when that disbanded, he was at a familiar crossroads. He had expanded his own neurosurgery abilities and realized that pain management was a natural companion niche. He reached out to five symbiotic specialty physicians to join him at Long Island Neuroscience Specialists, which opened its doors in 2000 in New York.

“Our goal initially was not to enhance income—it was purely based on finding the right person who was beneficial for the patient,” says Sathi. “But looking back, it’s had a positive financial impact on all the individuals in the practice.” Like Buford’s group, these specialists share overhead costs and employee salaries, and then divide the profits proportionately by patient load. The harder you work, the more money you bring home regardless of longevity with the group. He has not had an issue with the structure in the past nine years.

It’s likely the smaller size that caters to Sathi’s peaceable personality. “What I’ve found is that larger groups—it doesn’t even matter if it’s multispecialty or not—with the various personalities seem dysfunctional,” he says. “Maybe it works in an academic situation because not everybody has the same voting rights, but in private practice with equal partners, we’ve seen groups fall apart over the fighting.”

Hospital employees

PROS: Steady incomes where pay cuts aren’t as abrupt, physicians are able to better control their household budgets. Some hospital systems will pay student loans as part of the signing package in exchange for an agreement to stay between one and three years. Doctors in this model don’t need to fuss with patient billing, collections, and other payment hassles.

CONS: Physicians are still susceptible to business pressures to crank up the patient volume. Most human resource decisions are out of your hands—the hospital will select and hire your medical assistant, for example, and you still have to take your turn with night and weekend call schedules, so the hours are no steadier than private practice.

“I’ve seen hospitals put up with the most aberrant behavior, too, because they can’t lose that doctor’s access,” Bee says. “The hospital has to be tolerant because it’s hard to land some specialties, like primary care.” Translation: your colleagues may be pains.

FINANCIAL CONSIDERATIONS: When Randie Schacter, DO, interviewed with hospitals, she called colleagues in the area to find out that institution’s reputation in the area. If the medical community doesn’t respect the system, you’ll have a difficult time drumming up referrals, and a financially struggling hospital can mean your salary is set, but the equipment at your fingertips is not state-of-the-art.

BEST FITS: Residents who are already used to someone in a suit and tie telling them what to do and meticulous physicians who prefer to adapt to a program rather than create one.

THE REAL WORLD: Schacter interviewed with various practice opportunities for nearly a year before she found the right structure. A psychiatrist, she eventually chose a position with a guaranteed salary and full benefits at Presbyterian Hospital in Charlotte, North Carolina, over a large private group that wanted to bring her onboard to provide inpatient services. “I’m a social person and being in an office by myself without colleagues just didn’t work for me,” she says.

It’s not all roses, of course, when a corporation makes the decisions, and often the answer to a request or need is no. For instance, Schacter used to work later one night a week and leave early another for family time—a policy that changed while she was on maternity leave. No line of argument could change the situation.

The cases she sees on the inpatient side are more severe, and the call every ninth weeknight and ninth weekend is intense; she fields anywhere from 10 to 40 contacts a night from the ER and psych unit. Still, the payoff was worth it for her, if only because it takes financial uncertainty off her plate. “When I speak to colleagues—with the economy dropping, they’re not doing as well,” she says. “I know I’m getting a paycheck at the end of the month, and if my patients cancel, I’m still getting paid.” The hospital’s small productivity bonus sweetens the pot with some cash flow, too.

Her advice in the hospital arena is to negotiate the best salary you can upfront, because subsequent pay increases will never be simple. Also, if you have a family—Schacter has three girls—make sure the contract spells out enough vacation time for your lifestyle.

Contracted

PROS: A steady work schedule and the hospital provides the equipment and technology these doctors need to do their jobs.
There is no cash outlay or loans for expensive machines.

CONS: A contract for service with the hospital does not lower exposure to lawsuits, and the doctor is expected to pay his own malpractice insurance premiums and other benefits. These doctors may be expected to participate in community fund-raising efforts to secure money for new technology.

FINANCIAL CONSIDERATIONS: Pay is drawn from what is known as the “professional component” of a patient’s bill, which can range from a quarter to one-third of the global charge depending on the complexity of the test or service.

BEST FITS: Dedicated professionals who can provide good customer service to both patients and the hospital as clients.

THE REAL WORLD: Fate smiled on radiologist Melinda Staiger, MD, when she discovered a passion for breast imaging. Thanks to lawsuits running doctors out of this field, she has a high-demand practice niche carved out for her. During her career, she’s worked in two academic centers and in a private practice, but has found a good fit in her contract position as the director of breast imaging for Monmouth Medical Center, a community teaching hospital in New Jersey.

“You have to be very careful as a radiologist because with budget cuts and administrators really strapped for cash, the staffing and day-to-day systems needed to confirm patients are coming in for the biopsies you recommended, the follow-ups—things that can get me sued—may not be working,” she says. That’s why Staiger employs a person to work with doctors’ offices and keeps her own internal records. Most of the referring physicians are comfortable with her due diligence to make sure a patient got the necessary follow-up care.

Staiger triages cases throughout the day and will come in outside of office hours to provide service to an acute patient with a new development, but for the most part, she gives the predictable hours and opportunity to focus strictly on breast imaging a thumbs up. The other side? “When you’re part of a private group providing service, you may have a smaller pool of people to cover the hospital’s call and end up reading spine x-rays in the middle of the night” just because it was your turn, she says.

Academic research

PROS: Academic researchers work with more difficult cases, a challenge some find mentally stimulating. Their colleagues are cutting-edge medical stars, and researchers on average have a greatly reduced patient load. Research time is protected, and many work within a university’s 9 a.m. to 4 p.m. core hours.

CONS: Academia is intensely political. “In private practice, when a light bulb burns out, you will find me standing on a desk screwing in a new one,” Bee says. “In a university, you first have to call a fact-finding commission, have a conversation with the chancellor, and refer the matter to a subcommittee to get a new one.” Physicians here must be good writers as they will not only produce papers but apply for grants as well.

FINANCIAL CONSIDERATIONS: Insiders say the base pay is reasonable but not exciting; most academic researchers count paid travel and conference attendance among the financial perks, however.

BEST FITS: Physicians who are frustrated seeing 25 to 30 patients a day or bored diagnosing and treating the same symptoms. Idealists and dreamers also welcome. No matter who you are, you better like to write.

THE REAL WORLD: Gabriela Cora, MD, readily admits the prestige associated with conducting and publishing research appealed to her during her five years with the National Institutes of Health. She also got a kick from teaching what she knew and appreciated the hours. “I’ve always had a very analytical mind,” says the board-certified psychiatrist, who now runs the Executive Health and Wealth Institute at the Florida Neuroscience Center in Miami.

“So I loved to throw myself within a specific condition and learn as much as I could about it.” This indepth exploration meant getting to know her handful of patients on a more personal level than the average patient flow of the private arena allows. On the other hand, Cora wasn’t keen on the tedious and methodical issues surrounding research, and the competitive environment surrounding grants, proposals, and papers took her by surprise. She moved on to an industry position with Pfizer, which led to an MBA and her current corporate consultant practice.

Still, she recommends every physician spend some time in academia, even if they don’t intend to pursue it as a career. “It’s an important foundation in terms of how you think about the patient, what they’re presenting with, and the solutions,” she says.

Industry

PROS: Physicians will impact thousands of patients’ futures, and positions often offer opportunities for extensive travel.

CONS: Industry is a for-profit entity, which means physicians need to think in terms of return on investment—a foreign concept to medical schools. It’s also not a first stop on most doctors’ career paths—companies prefer to see a history of specialty practice or academic work.

FINANCIAL CONSIDERATION: When comparing salaries expressed in hourly rates, industry usually pays better than surgery.

BEST FITS: People with a strong sense of diplomacy and a head for profit numbers.

THE REAL WORLD: Janice Smiell, MD, was a solo practitioner in general surgery, running a wound care center, when she gave birth to her second child. “All I wanted was an opportunity to be part of my child’s life. I figured the only way that was going to happen would be to either work in a big group with a lot of coverage— which didn’t fit my style—or work in industry,” she says.

So, Smiell approached Johnson & Johnson about helping them develop their wound-healing drug on the drawing board. They said, “You’re hired.” Her colleagues simply gave her flack. “There was a perception that industry doctors basically sat around in the office doing very little so the company could put their names on stuff,” she says. “In reality, it takes a lot of time to develop a good protocol.”

Today, she is the vice president of medical affairs at LifeCell, a tissue-regeneration company in Morristown, New Jersey, where she is responsible for seeing that the studies on the products are well designed. She also makes sure the returned data is properly analyzed and any complaints are reviewed from a safety aspect. She handles regulatory reports and interacts with surgeons to understand the clinical aspects.

The transition between the two worlds did have its bumps in the road. Smiell found some of the projects that created anxiety among her team puzzling, especially after coming from life and death scenarios. “Over time, you do fall into that trap, though,” she says. “My stress now is more over not having enough time to do everything I’d like. “My hours are long but I can choose where I want to spend them, so I can get home and have dinner with my family. When I was in practice, that was pretty rare.”