I would love to have a practice in a small town (aprox 10K people) and then be able to drive and do a clinic day a few times a week at all the other surrounding smaller towns. How many doctors do you need to sustain such a practice? Two of my attendings were involved in a small rural practice that fell to pieces when a few of the doctors in town left, leaving only 3 or 4 physicians with hospital privileges which meant q 3-4 day call. Also, one of my other attendings used to be in private practice in such a town, and 'back in the day' took call for the OB, the peds, and the surgeon, but was working so much that his wife almost disowned him. After all, FM can cover all that, but those specialties can't reciprocate.
I know it's too early to be thinking about such a perfect practice as an intern, but I have to have something to dream about while I'm busy being docterized. So any insight into how to set up such a practice, or what to look for when joining a rural practice would be much apreciated.

When I was in residency 3 years ago, they told us about companies who help you set up your own practice. It takes approx 100,000K+ or more to set up your own. I personally don't see how you would do it unless you are independently wealthy as I have been working rural medicine for the past 3 years. All of those jobs were either employed or through locums.

From what I have seen just as an employee, some things to think about:

1. You need office space
2. You need a coder/biller unless you know how to do it yourself
3. You need equipment and supplies
4. An assistant or go without
5. A receptionist for scheduling
6. Do you know how to get an EIN/UPIN/Medicare/Medicaid numbers for that state?
7. Do you know how to get signed up with the various insurance companies so you can get paid?
8. Are you willing to be on call everyday?
9. Do you plan to do clinic and inpatient? OB?
10. Do you have a way for your clinic to be covered when you go on vacation?
11. You could just go cash pay and not worry about insurance or billing


If you plan on joining a practice you need to be aware that once you sign the papers you are owned by the company and usually its the office manager who runs your life. Beware of these people. I found that on salary I don't go home until the charting is done (6-8pm) while the mgr goes home at 5pm and has no problem bitching at you about your production and needing to see more patients.

If you have student loans in excess of 200K, be sure your base pay is at least 180K so you will be ahead of your bills each month. Beware of states that have state income tax as your paycheck dwindles quickly. For example: 180K in Oregon is 15K/month but after
federal/state taxes you barely clear 9K. That sounds like a lot but all said and done when you have a house, car, insurance, food, student loans, etc. that doesn't leave much left at the end of the month.

I personally will never work a salary job again as I will never be someone's slave again. I work locums and get paid by the hour so if I have to sit there for 12 hours to get everything done at least I get paid for my time.

I don't mean to be discouraging but just know that "the good ole days" are no longer. Obamacare is upon us. There is a huge shortage of family medicine docs especially in rural areas where back up is minimal and hours are very long.

When I was in residency 3 years ago, they told us about companies who help you set up your own practice. It takes approx 100,000K+ or more to set up your own. I personally don't see how you would do it unless you are independently wealthy as I have been working rural medicine for the past 3 years. All of those jobs were either employed or through locums.

From what I have seen just as an employee, some things to think about:

1. You need office space
2. You need a coder/biller unless you know how to do it yourself
3. You need equipment and supplies
4. An assistant or go without
5. A receptionist for scheduling
6. Do you know how to get an EIN/UPIN/Medicare/Medicaid numbers for that state?
7. Do you know how to get signed up with the various insurance companies so you can get paid?
8. Are you willing to be on call everyday?
9. Do you plan to do clinic and inpatient? OB?
10. Do you have a way for your clinic to be covered when you go on vacation?
11. You could just go cash pay and not worry about insurance or billing


If you plan on joining a practice you need to be aware that once you sign the papers you are owned by the company and usually its the office manager who runs your life. Beware of these people. I found that on salary I don't go home until the charting is done (6-8pm) while the mgr goes home at 5pm and has no problem bitching at you about your production and needing to see more patients.

If you have student loans in excess of 200K, be sure your base pay is at least 180K so you will be ahead of your bills each month. Beware of states that have state income tax as your paycheck dwindles quickly. For example: 180K in Oregon is 15K/month but after
federal/state taxes you barely clear 9K. That sounds like a lot but all said and done when you have a house, car, insurance, food, student loans, etc. that doesn't leave much left at the end of the month.

I personally will never work a salary job again as I will never be someone's slave again. I work locums and get paid by the hour so if I have to sit there for 12 hours to get everything done at least I get paid for my time.

I don't mean to be discouraging but just know that "the good ole days" are no longer. Obamacare is upon us. There is a huge shortage of family medicine docs especially in rural areas where back up is minimal and hours are very long.

Thanks for your input. I'm hoping to avoid being an employee of a larger corporation (under the guise of an ACO:rolleyes:) and would really like to join an existing practice if I can find one. If not...I guess I better start playing the lottery. You mentioned nightly call....how many docs can a town of 10K and surrounding communities really support? Weekly call would be nice but can you make $$$$ if there are 7 docs for 10K patients?

Most likely you will always be an employee even if you join an existing practice. Most are not self sufficient and belong to a greater group that covers the malpractice, health insurance, pay for the staff, the building, etc. You would most likely have a salary + RVU model.

I was stating nightly call as a worst case scenario. I am currently working locums in a town of 30K where there are around 12 permanent primary care docs. The doctors are struggling to take care of everyone and there is a huge shortage of primary care in this country. I seriously doubt you will find a town of 10K that has 7 doctors there who are not locums. The call depends on the set up that is agreed upon. It also depends on if you are admitting patient to the hospital, have hospitalist service or you admit your own. Too many variables. Essentially, until you have your student loans paid, you will be working for someone.

I live in a town of about 15 thousand. There are no locums here except occasionally in the ED. We are opening a satellite clinic in the next (smaller) town with in the next year. We have a physician owned practice, there are mid level, but no physician employees. I joined the practice. I can't imagine setting up my own practice from scratch, but I don't like the idea of being employed.

Here we have a physician's association that does contract negotiation and credentialing. It was 1K upfront and 600 dollars per year. They took care of all the insurance/medicare/medicaid credentialing. The hospital gave me a start up loan that is forgiven over a four year period. As long as I don't move in the next year, there will be no real start up costs for me. Our EMR does most of the coding and directly bills.. the office manager follows up on all claims not paid. It all can be overwhelming, and again I personally wouldn't want to go it alone, but it can be done.

Thanks for the other responses. There are plenty of scenarios out there. Some are good, some are bad, location does matter and some areas of the country are better provided for than others. Since I work locums I tend to be where there just aren't enough doctors. Every practice is different, every physician is different, it means being very careful about what you sign, have your contract lawyer go over every page.