Employed physicians are often torn. Many relish the steady salary and ability to focus on being a physician rather than handle administrative duties, but they bemoan their employers' rules and their lack of input into key decisions. And thus, many doctors are leaving employment to start a private practice. Seven physicians talked to Medscape about why they chose private practice.
Leaving Employment Is "an Invigorating Time"
On September 9, Aaron Przybysz, MD, gave notice to his employer, a large academic medical center in Southern California, that he would be leaving to start a private practice.
"It's an invigorating time," said Przybysz, 41, an anesthesiologist and pain management physician who plans to open his new pain management practice on December 1 in Orange County. He has picked out the space 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 concern that my business could fail. But even if that happens, what's the worst that could occur? I'd have to find a new job as an employed physician."
"I feel comfortable with the business side of medicine," he said. His father was an executive in the automotive industry and his father-in-law is an entrepreneur in construction and housing.
"One of the biggest reasons for moving to private practice is making sure I don't miss my kids' activities," he said, referring to his children, ages 9 and 7. A few weeks ago, "I had to spend the whole weekend on call in the hospital," he said. "I came home and had to sleep most of the next day."
"I love the people that I have been working with and I've learned and matured as a physician during that time," he said. "But it was time to move on."
The Desire to Be in Charge
In Medscape's recent Employed Physicians Report, doctors said they enjoy the steady salary and ability to focus on patients, which comes with being employed.
Other physicians feel differently. John Machata, MD, a solo family physician in the village of Wickford, Rhode Island, 20 miles south of Providence, chose private practice because "I have total control," he said. "I make decisions that I couldn't have made as an employed physician, such as closing my practice to new patients."
He can also decide on his work 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," said Machata. "They're always measuring your productivity. If you are slower, you won't make enough money for them."
When he worked for a large group practice about a decade ago, "I felt burnt out every day," he said. "I had to see patients every 10 minutes, with no breaks for anything in between. Within a month I was devising my exit strategy."
Machata maintains long appointments — 25 minutes for a typical follow-up visit and 55 minutes for an annual check-in — but he still earns above the state average for primary care doctors. "I have no nurse or front-office staff, which means I can save $125,000 to $150,000 a year," he said.
In 2018, for the first time, employed physicians outnumbered self-employed physicians, according to a survey by the American Medical Association (AMA). By the end of 2021, more than half (52.1%) of US physicians were employed by hospitals or health systems.
Yet the negatives of employment have begun to turn some physicians back toward private practice. Many physicians who were employed by a hospital or a 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, a solo practice in San Antonio, Texas, said he has "the best of both worlds."
"As a solo physician, I have total 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."
"You need a lot of administrative overhead to take on these contracts, which a private practice normally doesn't have," he said. But Bruggeman gets this work done through a clinically integrated network (CIN) of private practices, Spinalytics of Texas, where he is chief medical director.
The CIN represents 150 musculoskeletal care providers and provides access to bundled networks, such as a total joint bundle with Blue Cross Blue Shield of Texas, as well as fee-for-service contracts.
He 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 at the hospital, which will be useful for value-based contracts through the CIN.
Bruggeman said it would be hard to run his private practice without the CIN and the ASC. "Private practice has changed," he said. "The days of hanging up a shingle and immediately being successful are gone. You've got to be smart about business to run a successful practice."
He Started His Practice While the Pandemic Raged
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 did not stop him.
"Federal financing of small bank loans completely stopped, but that only amounted to a small delay because our bank took care of it," said Greene, who co-directs his new practice with another orthopedic surgeon.
Even during the pandemic, "we could be very nimble," he said. "For instance, when we want to institute new technology or a new patient-centric educational platform, we can do it immediately rather than going through an approval process at a health system."
The partners, both ex-employees of a health system, also have an ASC, which allows them better control over their surgery schedules. "At a hospital, you can be bumped from the schedule by other surgeries, and you can't be as productive as an ASC in the number of surgeries per day," he said.
Greene attributes the practice's success to long and careful planning. "We had to learn about business," he said. "We did 3 to 4 years of research to find the right business model and implement it."
As they were considering the new practice, a survey of patients showed that more than 75% chose them by word-of-mouth — because they specialize in complex and revision surgeries — rather than through referrals within their health system. This meant they could survive without their employer.
Planning for the new practice took up all his free time, but now he can relax and spend time with his three daughters, ages 12, 10, and 8. Greene currently coaches two of their teams. "We're loving it," he said.
Colleagues Want to Know How He Did it
Clinton Sheets, MD, an ophthalmologist in Hudson and Clearwater, Florida, went solo in 2019 after being in a group practice for 11 years. Since he opened up, "I get phone calls from colleagues all the time, asking me about 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 competence, you can outsource as much or as little as you want. Some management companies can do almost all of the nonclinical work for you.
"Smaller practices can streamline processes because they have a flatter organizational structure and have fewer issues with administrative bloat than larger organizations," he said.
"Technology hinders and helps a private practice," he said. On the one hand,
he had to buy a lot of expensive equipment that otherwise would be shared by a group of doctors. On the other hand, using the cloud makes it possible to easily store practice management software and the electronic health record.
He's Opening a Private Practice While Staying Employed
In December, Dev Basu, MD, a hospitalist in Baltimore, Maryland, plans to start his own private practice, seeing patients in skilled nursing homes, while still working as a nocturnist in a large healthcare system.
He said his employer has been supportive of his plans. "My work will not directly compete with them and it will benefit them by serving patients discharged from their hospitals," said Basu, 38. He added, however, that he will only be allowed 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 won't have a staff or an office." He plans to maintain his full schedule as an employee, working 12 nights a month, because it will give him a great deal of time to do the new work.
"I also have no particular interest in running a business," he said. "I come from a family of doctors, professors, and teachers who never ran a business. But I'm willing to learn so that I can practice medicine the way I want to."
"The ability to set my own schedule and deal with patients in the way I think is best is very important to me," he said.
Private Practitioners Don't Have to Face "Moral Distress"
One thing private practitioners typically don't have to contend with is "moral distress," which occurs when you have to follow institutional concerns on how much time you can spend with a patient or on the need to keep referrals in-house, according to Marie T. Brown, MD.
Brown is an internist who ran a small private practice in Oak Park, Illinois, and is now the physician lead for the American Medical Association's STEPS Forward program, which provides strategies on how to improve a medical practice.
"In my private practice, I could control the time I spent with each patient," she said. "I also had control over my schedule. If I didn't have the time, I just took a lower income, but that was okay."
Brown said it is a myth that employment offers a better work-life balance. "Young physicians who take employment for this reason may find that they're not allowed to drop off and pick up their children from school at a certain time. But you can do that in a private practice."
She said it's not that hard to run a practice. "Young physicians don't think they could run a practice because they don't have any business skills," she said. "Yes, you do need some management skills, and you have to devote time to management. But you don't need to have special expertise. You can outsource much of the work."
A Growing Trend?
David J. Zetter, a consultant in Mechanicsburg, Pennsylvania who helps doctors set up private practices, sees more interest in this in the past 5 years. "The overwhelming trend used to be private practices being bought up by hospitals and other entities," he said. "Now we're seeing the pendulum swing in the opposite direction."
"Generally, these doctors are fed up with being employed at a large organization," he added. "Recently I got a call from a doctor who had never thought about running his own business, but he's had it with being an employed physician."
Switching to private practice is scary for a lot of them, but the alternative is worse. "A podiatrist I'm working with tells me she is scared to death about setting up a private practice, but she's doing it because she doesn't want to be employed anymore," Zetter said.
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Cite this: Why Private Practice Will Always Survive: 7 Doctors Who Left Employment Tell Why - Medscape - Sep 29, 2022.