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November 18, 2020

What’s your best practice fit?

 

Moses Graubard, M.D.

Working as an employee opens research and learning opportunities as well as tracks for advancement, says Moses Graubard, M.D. - Photo by Apollo Fotagrafie

Once upon a time, most physicians came out of medical school with plans to open their own practices. "That’s how it was when I was growing up," says Leland Rosenblum, M.D., ophthalmologist and owner of Monterey Bay Eye Center in Monterey, California, and co-owner of Monterey County Eye Associates.

As a child, he’d seen the private practice model up close. His grandfather, a family physician, owned a practice in New York City. Rosenblum recalls that owning a practice was the norm and working for an employer was less common. That is, he says, until "around the mid-90s, when I came out of training. At that point, physicians started to look at employment differently."

Fast forward to today. Young physicians aren’t just open to employment; they tend to favor it - especially early in their careers. In a 2019 survey by Merritt Hawkins, 91 percent of residents said they’d prefer to be employed than practice independently. The same survey found that 43 percent of respondents preferred hospital employment - the single most popular option. Only seven percent and two percent, respectively, said they wanted to partner with another physician or set up a solo practice.

Whether it’s the appeal of financial stability, the increasing consolidation of practices or an aversion to business management, more and more of today’s residents are leaning toward salaried positions. But it’s surely not a one-size-fits-all decision.

Jaimela Dulaney, M.D., cardiologist and owner of a concierge cardiology, internal medicine and nutrition practice in Port Charlotte, Florida, says owning a practice offers her a quality of life that was hard to find as an employee. "My father - a business owner, not a physician - gave me advice when I was trying to decide how to manage my career," she says. "He said, ’If somebody has a skill where they can work for themselves, why would they work for anybody else?’"

Before launching her one-of-a-kind, plant-based concierge practice in 2017, Dulaney had practiced in many settings - including academic medicine, employment and partnership tracks in small and large groups, and a solo cardiology practice. Now as an owner, she says she has more control over her work life and the freedom to pursue clinical passions that don’t necessarily line up with corporate priorities.

Both ownership and employment have their own benefits and drawbacks. The key is to consider your personality and your aspirations, then evaluate which model lines up with your short- and long-term goals.

The quest for work/life balance

Leland Rosenblum, M.D.

Leland Rosenblum, M.D., sees the business side of managing his own practice as a creative outlet. "There’s always a new way to grow it," he says. - Photo by Anne Maries Photography

Of all the reasons young physicians give for preferring employment, work/life balance may be the most compelling. That’s the case for Moses Graubard, M.D., an emergency and pain medicine physician with The Permanente Medical Group (TPMG), the physician organization of Kaiser Permanente, in Oakland, California.

Graubard says his job supports him in both his personal and professional lives. "I believe I work fewer hours than I would in private practice," he says, adding that TPMG’s culture offers built-in flexibility. "In addition to clinical practice, our group can offer physicians opportunities that might not be available outside of Kaiser Permanente, such as research and teaching."

He also appreciates that advancement opportunities are abundant, but there’s no pressure to pursue them. Senior physicians can go after leadership or administrative roles if they want to, while physicians who prefer to focus on patient care can leave almost all of the business dealings to others.

The idea of just focusing on medicine is a draw for many physicians. But Rosenblum believes younger physicians may not realize how much can be gained, especially in regard to work/life balance, by taking on more business responsibilities. A great deal depends on practice structure. If flexibility is a priority for practice owners, they can build it into the organization from the start.

"I’ve noticed younger physicians are very concerned about quality of life and work/life balance, especially because the financial rewards [of being a physician] are less than they once were. These are some of the best and brightest people, and they see that - compared to their friends in finance or software - the economic rewards of medicine aren’t as great," he says. "Growing up through 9/11 and the 2008 recession has given them a different sense of the world. They want more security. But they may not realize that private practice may offer more of the balance they’re also looking for."

Gregory Harris, D.O., hematologist/oncologist and practice owner of Harbin Clinic Cancer Center in Rome, Georgia, agrees. "A lot of people like the stability of just knowing ’I show up. I see my set number of patients per week, and I get paid the same,’" he says. But the chance for better work/life balance and more family time inspired him to pursue practice ownership right from the start of his career.

Harris says that the key is to "find the right group of like-minded physicians." By design, his group prioritizes flexibility and time off for physicians. "We all work four days. We each have a wellness day every week. We also require four weeks of vacation, but some of us take up to six or seven." He believes it’s crucial to assess factors like these before deciding whether to pursue ownership or employment.

Kori Hunt, M.D., a family physician with Grants Pass Clinic in Grants Pass, Oregon, remembers being interviewed by a partner for an employee position at the clinic a few years ago. She was surprised and impressed when the partner told her: "I’ve never had to miss one of my daughter’s games."

About a year after she joined the clinic, Hunt became a partner herself. She now works part time so she can have more time with her own daughter.

Conventional wisdom isn’t always right

Dulaney was also concerned about work/life balance while raising her child. She was on the partnership track at a large group when she took the unexpected step of opening a solo cardiology practice.

"That’s not supposed to work for a cardiologist. How do you survive call?" she remembers. "But I took my own call and worked out an arrangement for a group to cover for me when I went out of town. It was a lot of years of seven-days-a-week call. I was busy, but I made it work."

She might have been busier, but by hanging out her shingle, Dulaney felt she had more freedom. "As a single mother, I wanted to have some control over my life. [With a solo practice], I could let people know that there were days I’d be coaching track."

She went against the grain again recently by converting her practice to a concierge model. Patients who share her vision of preventive cardiology care through exercise, community and plant-based nutrition pay a monthly subscription fee for her services. This has allowed Dulaney to reduce her patient panel to about a fifth of what it was as a conventional cardiology practice.

Harris’s group has also defied conventional wisdom. Since oncology has high overhead costs and requires referrals to stay afloat, many people believe it’s not compatible with a private practice model. His group has adapted by operating like several smaller practices under one umbrella. They share overhead costs to increase their purchasing power.

The group’s location helps this model work, too. They’re able to build referral relationships because, as Harris says: "It’s a very medical town." Though the city of Rome is relatively rural, it has two hospitals to serve Floyd County and the surrounding area.

Initially, Hunt thought ownership wasn’t for her. "Being a partner and business owner didn’t cross my mind at first, because I thought I’d have to be involved in all the business details," she explains.

Instead, she found that her group’s partners participate in strategic decisions at a board level. To free physicians to focus on medicine, the group has dedicated management and clear formulas for determining partner income and sharing overhead. Transparency is central to their business philosophy, and each partner maintains complete control over his or her schedule.

"I was worried I’d get bogged down in details like billing and hiring and firing," Hunt says. "Our structure allows me to focus on being a doctor but still have control over my practice."

Clinical decision-making and quality of life

Preconceived notions about large employers can also be misleading. That’s why Graubard says job seekers should ask how an organization handles clinical decision-making. There can be significant differences from employer to employer, and these have a big impact on a physician’s work life.

At TPMG, he says, "Our whole organization is run by doctors. Everyone understands what everyone else is dealing with." The Kaiser Permanente umbrella comprises TPMG, a hospital organization and a health plan. This means TPMG physicians don’t have to worry about whether or not their services will be covered by insurance.

Not having to deal with insurance hassles increases quality of life for TPMG physicians. According to Graubard, it creates a more cooperative environment. "We all - the insurance company, the hospitals and our group - depend on each other for our success," he says.

Kaiser Permanente is not the only organization with this type of setup. Graubard mentioned Intermountain and Geisinger as other examples and noted there are probably more. The best way to find out how an organization is structured is to ask. You can also reach out to your connections to get an insider’s perspective.

"I urge residents to really use your alumni network from residency," Graubard recommends. "It’s so helpful to talk to people who are already working." Even better, networking might help you learn about an opening before it’s even advertised.

Of course, independent clinical decision-making is also one of the most appealing benefits of practice ownership. Some private practices, such as Dulaney’s and Harris’s, take clinical decision-making to a whole new level.

In Dulaney’s case, a family history of cardiac problems set her on the path to cardiology and ignited her passion for prevention. A marathon runner, she focused at first on introducing patients to exercise. Then, books about veganism caught her attention. She wanted to work nutrition into her practice, but she found this hard to do while employed by a large group.

"I wanted to do a nutrition class and do plant-based cardiology, but the way the group was structured, there was no way to do it and survive," she explains. "We were caught up in the wheel of seeing a certain number of patients, taking enough call, doing enough hospital work." Dulaney was welcome to pursue her ideas for educating patients - but only in her free time. Ultimately, she developed a new vision for a solo practice focused on plant-based nutrition.

Nutrition was also a keen interest of Harris’s. He recognized that his rural cancer patients might not have access to nutrition information that could help them be healthier. "We brought on a full-time nutritionist who could meet with patients while they’re in the office getting chemo. In a major company, would I be able to just hire someone like that? They would probably say, ’Why would we do that when we can’t bill for it?’" he says. "In our group, we can decide to just do something like this that can make a huge change for our patients and will cost us very little."

Variety and learning lead to long-term career satisfaction

For many practice owners, creating protocols and policies that improve patient care is a big plus. As Hunt says, "We can decide what we feel comfortable with and what we feel is best and safe for patients and ourselves."

At Harris’s practice, one key component of this is preventing burnout since physician morale is essential for patient care in oncology. "Our patient relationships are long-term," he says. "We must have good quality of life so that we can be there for them. It comes down to the right set of features."

The ideal work situation is different for everyone. Whether you’re looking for a job with a large organization or joining a private group with the possibility of partnership, Harris urges physicians to consider fit very carefully. And if you’re planning to partner up with other physicians and start a new group, take advantage of the opportunity to make decisions that improve job satisfaction.

As for Harris, he’s found that improving operations is very rewarding. "Patient efficiency is my passion," he says. "I don’t think patients should have to sit around and wait. I ask, ’Can we improve the lab or check-in and check-out to make them work better?’" Tinkering with the workflow inspires him. It’s another intellectual outlet that keeps him engaged with his practice. Because he’s a practice owner, he can make improvements without a long corporate approval process.

Rosenblum regards the business side of his practice as a form of creative expression. In fact, he says it can be fun. "I’m an imperfect business manager, but that’s the exciting thing about being in business," he explains. "There’s always a new way to grow it, to tweak things and improve efficiency. It’s a way to exercise the non-medical side of my brain."

When Dulaney started to plan her plant-based concierge practice, she found a zest for other business disciplines, such as strategy and marketing. These newfound interests helped her promote both her practice and her message.

So far, she has recorded more than 200 episodes of her plant-based wellness podcast in addition to developing classes, writing cookbooks and even partnering with a fine dining restaurant to offer special vegan selections. "I’ve found I enjoy writing all of a sudden," she says. "I see that aspect of my career growing. It has put new life into my practice of medicine."

Graubard adds that a large organization may offer similar ways to refresh your intellectual side and pursue professional growth. For example, he was able to take a year’s leave from his job to pursue a pain medicine fellowship. This wasn’t just a stimulating, recharging experience but also an invaluable career step that expanded his practice options.

Do financial concerns supersede all else?

For many residents, finances override all other career concerns. As Hunt says, "So many physicians graduate with so much debt, it’s like you have a mortgage payment without the house. It’s understandable that hospitals and other large employers that can offer loan repayment are attractive. Private groups, even large ones, may not be able to compete with that."

The 2019 Medscape Physician Compensation Report found that self-employed physicians in their survey earned about 24% more than employed ones. But a lot depends on your specialty and market. Rosenblum says California’s high cost of living means it’s often more lucrative to be employed within a larger system, at least initially. "They can offer a bigger starting base and a bonus to help buy a home." Plus, in some specialties, physicians might not find many private group opportunities when they’re just starting out, and opening your own practice typically means delaying financial rewards.

Graubard says, "Here in the East Bay area, I believe it’s estimated that Kaiser Permanente members are about half the insured population." That market dominance makes it more challenging to build a private practice - though not impossible. He adds that this competition, along with the tougher economic environment in California, keeps TPMG focused on providing a good work environment and financial benefits to attract and retain the best physicians.

Planning for the long term

If you’re just starting out and need to prioritize finances, employment might be a good move. "But I recommend keeping your eyes open," says Hunt. You might find yourself in a job that suits your personality perfectly, but if not, you have options.

When Harris began learning about opening a private practice, he relied on others’ expertise. "I had three very knowledgeable mentors who showed me the books, literally." The right mentor can be hard to find. That’s why, now that he has the opportunity to give back, Harris has become one himself. "I talk to residents about the business of medicine and quality of life and work/life balance," he says. "I try to get people to start thinking about these things earlier. It’s not all about money, but about quality of life and how you want to live it."

Rosenblum agrees. "This may sound trite, but I still look at the practice of medicine as a privilege and honor," he says. "The role you’ll play in peoples’ lives is transformative. Finding the environment that is right for you, whether in private practice or employment, is more important than a few extra dollars. Enjoy the process of learning and becoming."

Many private practice physicians share this willingness to try new things and pursue a happier life. But risk-taking requires careful planning, too. Avoiding lifestyle inflation while you’re employed can help you save money to build your own practice. It also helps to make a Plan B.

Dulaney did just that when she started her solo practice. "I knew that if this flunked, I had a backup plan," she says. "I realized I could get part-time work at the ER." She advises physicians to think about alternate income options if pursuing a passion project takes longer than expected.

"Remember that as a physician, you have the opportunity to do a whole host of things," she says. "In the practice of medicine and the practice of life, you hone what’s right for you as you go along."



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