"Everyone says private practice is dying," says Omar Maniya, MD, an emergency physician who left his hospital job for family practice in New Jersey. "But I think it could be one of the best models we have to advance our healthcare system and prevent burnout — and bring joy back to the practice of medicine."
Last year, the American Medical Association found that, for the first time, less than half of all physicians work in private practice. But employment doesn't necessarily mean happiness. For the report Employed Physicians: Loving the Focus, Hating the Bureaucracy, Medscape surveyed more than 1350 US physicians employed by a healthcare organization, hospital, large group practice, or other medical group about their work. As the subtitle suggests, many are torn.
In the survey, employed doctors cited three main downsides to the lifestyle: They have less autonomy, more corporate rules than they'd like, and lower earning potential. Nearly one third say they're unhappy about their work-life balance, too, which raises the risk for burnout.
Some physicians find that employment has more cons than pros and turn to private practice instead.
A System Skewed Toward Employment
In the mid-1990s, when James Milford, MD, completed his residency, going straight into private practice was the norm. The family physician bucked that trend by joining a large regional medical center in Wisconsin. He spent the next 20+ years working to establish a network of medical clinics.
"It was very satisfying," Milford says. "When I started, I had a lot of input, a lot of control."
Since then, the pendulum has been swinging toward employment. Brieanna Seefeldt, DO, a family physician outside Denver, completed her residency in 2012.
"I told the recruiter I wanted my own practice," Seefeldt says, "They said if you're not independently wealthy, there's no way."
Sonal G. Patel, MD, a pediatric neurologist in Bethesda, finished her residency the same year as Seefeldt. Patel never even considered private practice.
"I always thought I would have a certain amount of clinic time where I have my regular patients," she says, "but I'd also be doing hospital rounds and reading EEG studies at the hospital."
For Maniya, who completed his residency in 2021, the choice was simple. Growing up, he watched his immigrant parents, both doctors in private practice, struggle to keep up.
"I opted for a big, sophisticated health system," he says. "I thought we'd be pushing the envelope of what was possible in medicine."
Becoming Disillusioned With Employment
All four of these physicians are now in private practice and are much happier.
Within a few years of starting her job, Seefeldt was one of the top producers in her area but felt tremendous pressure to see more and more patients. The last straw came after an unpaid maternity leave.
"They told me I owed them for my maternity leave, for lack of productivity," she says. "I was in practice for only 4 years, but already feeling the effects of burnout."
Patel only lasted 2 years before realizing employment didn't suit her.
"There was an excessive amount of hospital calls," she says. "And there were bureaucratic issues that made it very difficult to practice the way I thought my practice would be."
It took just 18 months for Maniya's lightbulb moment. He was working at a hospital when COVID-19 hit.
"At my big healthcare system, it took 9 months to come up with a way to get COVID swabs for free," he says. "At the same time, I was helping out the family business, a private practice. It took me two calls and 48 hours to get free swabs for not just the practice, not just our patients, but the entire city of Hamilton, New Jersey."
Milford lasted the longest as an employee — nearly 25 years. The end came after a healthcare company with hospitals in 30 states bought out the medical center.
"My control gradually eroded," he says. "It got to the point where I had no input regarding things like employees or processes we wanted to improve."
Making the Leap to Private Practice
Private practice can take different forms.
Seefeldt opted for direct primary care, a model in which her patients pay a set monthly fee for care whenever needed. Her practice doesn't take any insurance besides Medicaid.
"Direct primary care is about working directly with the patient and cost-conscious, transparent care," she says. "And I don't have to deal with insurance."
For Patel, working with an accountable care organization made the transition easier. She owns her practice solo but works with a company called Privia for administrative needs. Privia sent a consultant to set up her office in the company's electronic medical record. Things were up and running within the first week.
Maniya joined his mother's practice, easing his way in over 18 months.
And then there's what Milford did, building a private practice from the ground up.
"We did a lot of googling, a lot of meeting with accountants, meeting with small business development from the state of Wisconsin," he says. "We asked people that were in business, 'What are the things businesses fail on? Not medical practices, but businesses.'" All that research helped him launch successfully.
Making the Dollars and Cents Add Up
Moving from employment into private practice takes time, effort, and of course, money. How much of each varies depending on where you live, your specialty, whether you choose to rent or buy office space, staffing needs, and other factors.
The four doctors in this story illustrate the range:
Seefeldt got a home equity loan of $50,000 to cover startup costs — and paid it back within 6 months.
Purchasing EEG equipment added to Patel's budget; she spent $130,000 of her own money to launch her practice in a temporary office and took out a $150,000 loan to finance the buildout of her final space. It took her 3 years to pay it back.
When Milford left employment, he borrowed the buildout and startup costs for his practice from his father, a retired surgeon, to the tune of $500,000.
Maniya assumed the largest risk. When he took over the family practice, he borrowed $1.5 million to modernize and build a new office. The practice has now quintupled in size. "It's going great," he says. "One of our questions is, should we pay back the loan at a faster pace rather than make the minimum payments?"
Several years in, Patel reports she's easily making three to four times as much as she would have at a hospital. However, Maniya's guaranteed compensation is 10% less than his old job.
"But as a partner in a private practice, if it succeeds, it could be 100%-150% more in a good year," he says. On the flip side, if the practice runs into financial trouble, so does he. "Does the risk keep me up at night, give me heartburn? You betcha."
Milford and Seefeldt have both chosen to take less compensation than they could, opting to reinvest in and nurture their practices.
"I love it," says Milford. "I joke that I have half as much in my pocketbook, twice as much in my heart. But it's not really half as much, 5 years in. If I weren't growing the business, I'd be making more than before."
Private Practice Is Not Without Challenges
Being the big cheese does have drawbacks. In the current climate, staffing is a persistent issue for doctors in private practice — both maintaining a full staff and managing their employees.
And without the backing of a large corporation, doctors are sometimes called on to do less than pleasant tasks.
"If the toilet gets clogged and the plumber can't come for a few hours, the patients still need a bathroom," Maniya says. "I'll go in with my $400 shoes and snake the toilet."
Milford points out that when the buck stops with you, small mistakes can have enormous ramifications. "But with the bad comes the great potential for good. You have the ability to positively affect patients and healthcare, and to make a difference for people. It creates great personal satisfaction."
Is Running Your Own Practice All It's Cracked Up to Be?
If it's not yet apparent, all four of these doctors highly recommend moving from employment to private practice when possible. The autonomy and the improved work-life balance have helped them find the satisfaction they'd been missing while making burnout less likely.
"When you don't have to spend 30% of your day apologizing to patients for how bad the healthcare system is, it reignites your passion for why you went into medicine in the first place," says Maniya. In his practice, he's made a conscious decision to pursue a mix of demographics. "Thirty percent of our patients are Medicaid. The vast majority are middle to low income."
For physicians who are also parents, the ability to set their own schedules is life-changing.
"My son got an award last week, and the teacher invited me to the assembly. In a corporate-based world, I'd struggle to be able to go," says Seefeldt. As her own boss, she didn't have to forgo this special event. Instead, she coordinated directly with her scheduled patient to make time for it.
In Medscape's report, 61% of employed physicians indicated that they don't have a say on key management decisions. However, doctors who launch private practices embrace the chance to set their own standards.
"We make sure from the minute someone calls they know they're in good hands, we're responsive, we address concerns right away. That's the difference with private practice — the one-on-one connection is huge," says Patel.
"This is exactly what I always wanted. It brings me joy knowing we've made a difference in these children's lives, in their parents' lives," she concluded.
Debbie Koenig is a writer specializing in health and nutrition, and the author of the cookbook Parents Need to Eat Too: Nap-Friendly Recipes, One-Handed Meals & Time-Saving Kitchen Tricks for New Parents(William Morrow). Her work has appeared in Diabetic Living, Cooking Light, The Washington Post, The New York Times, and the Best Food Writing anthology, among others.
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Cite this: Should You Quit Employment to Open a Practice? These Docs Share How They Did It - Medscape - Dec 13, 2022.