Why Private Practice Will Always Survive

Employed doctors are often torn. Many enjoy the steady salary and the ability to focus on being doctors instead of handling administrative tasks, but they bemoan their employers’ rules and their lack of involvement in key decisions. And so many doctors are leaving employment to start a private practice. Seven doctors spoke to Medscape about why they chose private practice.

Leaving a job is “an exhilarating time”

On September 9, Aaron Przybysz, MD, notified his employer, a large academic medical center in Southern California, that he was leaving to start a private practice.

“It’s an exciting time,” said Przybysz, 41, an anesthesiologist and pain management physician who plans to open his new pain management practice Dec. 1 in Orange County. He has chosen the space that he will rent but has not yet hired his staff.

“I’ve been serious about doing this for at least a year,” Przybysz said. “What held me back is the worry that my business might fail. But even if that happens, what’s the worst that could happen? I’d have to find a new job as an employed doctor.”

“I’m comfortable with the business side of medicine,” he said. Her father was an executive in the auto industry and his father-in-law is a construction and housing entrepreneur.

“One of the biggest reasons for moving into private practice is to make sure I don’t miss my kids’ activities,” she said, referring to her sons, ages 9 and 7. A few weeks ago, “I had to spend the entire weekend on call at the hospital,” she said. “I got home and had to sleep most of the next day.”

“I love the people I’ve been working with and have learned and matured as a doctor during that time,” he said. “But it was time to move on.”

The desire to be in charge

In the recent Medscape report Employed Physician ReportThe doctors said they enjoy a steady salary and the ability to focus on patients, which comes with employment.

Other doctors feel differently. John Machata, MD, a solo family physician in the town of Wickford, Rhode Island, 20 miles south of Providence, chose private practice because “I’m in complete control,” he said. “I make decisions that I couldn’t have made as an employed physician, like closing my practice to new patients.”

You can also decide on your working hours. “I see patients for 35 hours, 4 days a week, and then I have a 3-day weekend.” In a large organization, “the focus is on revenue,” Machata said. “They’re always measuring your productivity. If you’re slower, you won’t make enough money for them.”

When he worked for a large group practice a decade ago, “I felt burned out every day,” he said. “I had to see patients every 10 minutes, with no breaks at all in between. Within a month I was designing my exit strategy.”

Machata keeps long appointments (25 minutes for a typical follow-up visit and 55 minutes for an annual checkup), but still earns above the state average for primary care physicians. “I don’t have a nurse or front desk staff, which means I can save $125,000 to $150,000 a year,” she said.

In 2018, for the first time, physicians employed outnumbered on their own doctors, according to a survey by the American Medical Association (AMA). At the end of 2021, more than half (52.1%) of US physicians were employed in hospitals or health systems.

However, negative aspects of employment have begun to drive some doctors back into private practice. Many physicians who were employed by a hospital or large practice have become disillusioned and want to return to private practice.

His practice is “the best of both worlds”

Adam Bruggeman, MD, a 42-year-old spine surgeon who is CEO of Texas Spine Care Center, an individual practice in San Antonio, Texas, he said he has “the best of both worlds”.

“As a solo physician, I have complete control over how I practice,” he said. “But I also have access to value-based contracts and the data and staff needed to implement them.”

“It takes a lot of administrative overhead to take on these contracts, which a private practice typically doesn’t have,” he said. But Bruggeman does this work through a clinically integrated network (CIN) of private practices, Spinalytics of Texas, where he is chief medical director.

CIN represents 150 musculoskeletal care providers and provides access to pooled networks, such as a total joint package with Blue Cross Blue Shield of Texas, as well as fee-for-service contracts.

It is also building a new ambulatory surgery center (ASC) that is scheduled to open in January.. There he plans to perform total joint and spine surgeries at a lower cost than in the hospital, which will be helpful for value-based contracts through the CIN.

Bruggeman said it would be difficult to run his private practice without the CIN and ASC. “Private practice has changed,” he said. “The days of hanging up a shingle and immediately being successful are gone. You have to be business savvy to run a successful practice.”

He started his practice while the pandemic was raging

Joe Greene, MD, 42, an orthopedic surgeon in Louisville, Kentucky, had to open his hip and knee surgery practice when the COVID-19 pandemic was raging a year and a half ago, but that didn’t stop him.

“Federal funding of small bank loans was completely stopped, but that was only a small delay because our bank took care of that,” said Greene, who co-runs his new practice with another orthopedic surgeon.

Even during the pandemic, “we could be very nimble,” he said. “For example, when we want to institute a new technology or a new patient-centric educational platform, we can do it immediately instead of going through an approval process in a health system.”

The partners, both former employees of a health system, also have an ASC, which allows them better control over their surgery schedules. “In a hospital, other surgeries can take you off schedule and you can’t be as productive as an ASC in the number of surgeries per day,” he said.

Greene attributes the success of the practice to long and careful planning. “We had to learn about business,” he said. “We did 3-4 years of research to find the right business model and implement it.”

While considering the new practice, a survey of patients showed that more than 75% chose them through word of mouth, because they specialize in complex and revision surgeries, rather than referrals within their health system. This meant that they could survive without their employer.

Planning for the new practice took up all her free time, but now she can relax and spend time with her three daughters, ages 12, 10 and 8. Greene currently coaches two of her teams. “We love it,” she said.

Colleagues want to know how you did it

Clinton Sheets, MD, an ophthalmologist in Hudson and Clearwater, Florida, became independent in 2019 after being in a group practice for 11 years. Since it opened, “I get phone calls from colleagues all the time, asking how I did it,” he said. “At least two of them followed in my footsteps.”

“I tell them it’s very doable,” he said. “If you have the motivation, you can do it. Depending on your competency, you can outsource as much or as little as you want. Some management companies can do most of the non-clinical work for you.

“Smaller practices can streamline processes because they have a flatter organizational structure and have fewer issues with administrative overhead than larger organizations,” he said.

“Technology both hinders and helps a private practice,” he said. On the one hand,

he had to buy a lot of expensive equipment that would otherwise be shared by a group of doctors. On the other hand, the use of the cloud allows easy storage of the practice management software and the electronic medical record.

You are opening a private practice while you remain employed

In December, Dev Basu, MD, a hospitalist in Baltimore, Maryland, plans to start her own private practice, seeing patients in specialized nursing homes, while continuing to work as a night clerk in a large health care system.

He said his employer has supported his plans. “My work will not directly compete with them and will benefit them by caring for patients discharged from their hospitals,” said Basu, 38. He added, however, that he will only be able to work at certain facilities, and these will be subject to annual review.

“The financial risk of the new practice is low, because I haven’t had to invest much,” he said. “I will have no staff or office.” He plans to keep his full schedule as an employee, working 12 nights a month, because it will give him plenty of time to do the new job.

“I also have no particular interest in running a business,” he said. “I come from a family of doctors, professors and teachers who have never run a business. But I am willing to learn so I can practice medicine the way I want.”

“The ability to set my own hours and treat patients the way I think is best is very important to me,” he said.

Private doctors do not have to face “moral anguish”

One thing private doctors don’t typically have to deal with is “moral anguish,” which occurs when you have to follow institutional concerns about how much time you can spend with a patient or about the need to keep internal referrals, according to Marie T. Brown, MD.

Brown is an internist who ran a small private practice in Oak Park, Illinois, and is now lead physician for the American Medical Association’s STEPS Forward program, which provides strategies on how to improve a medical practice.

“In my private practice, I was able to control the time I spent with each patient,” he said. “I also had control over my schedule. If I didn’t have the time, I would just take a lower income, but that was fine.”

Brown said it’s a myth that employment offers a better work-life balance. “Young doctors who take employment for this reason may find that they are not allowed to drop off and pick up their children from school at a certain time. But they can do it in a private practice.”

She said it’s not that hard to run a practice. “Young doctors don’t think they can run a practice because they don’t have any business skills,” she said. “Yes, you need some management skills and you have to spend time managing. But you don’t need to have special experience. You can outsource a lot of the work.”

A growing trend?

David J. Zetter, a consultant in Mechanicsburg, Pa., who helps doctors set up private practices, sees more interest in this in the last 5 years. “The overwhelming trend used to be private practices bought out by hospitals and other entities,” he said. “Now we’re seeing the pendulum swing in the opposite direction.”

“Usually these doctors are tired of working in a large organization,” he added. “I recently got a call from a doctor who had never thought about running his own business, but got tired of being an employed doctor.”

Switching to private practice is scary for many of them, but the alternative is worse. “A podiatrist I’m working with tells me she’s scared to death of setting up a private practice, but she’s doing it because she doesn’t want to have a job anymore,” Zetter said.

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