How old is too old for solo PP?

[Otomim]

hey guys first time poster here.
I'm a junior attending at an academic center, 4 years out from fellowship.
I'm a bit burned out and disillusioned by the academic world -- don't have the motivation to keep grinding, writing grants/papers, going to conferences, going to multiple meetings during the week, etc. I also have 2 young kids I want to spend more time with.
I turn 40 next year and I wanted to ask any solo practioners out there (or anyone who knows people in solo practice) how long it took to ramp up his/her clinical volume. I am wondering if I am too old to consider a venture into the solo PP world, since I'm sure it takes time to build a practice.

Having lived and breathed academics my career thus far, I'm a bit intimidated by making a big jump into general ENT, solo at that. However, it's something that I've always wanted to do and I'm thinking about making the move next year. I am looking into group practice as well, but to be honest, I like the idea of having full control of my schedule/practice so leaning more towards solo. Any advice or perspectives would be very appreciated.

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[Pir8DeacDoc]

First thought- you will likely practice ENT for 20-25 more years. You might as well do it on the terms that you want. Though to be fair, I wonder if the desire to spend more time with family will be realized while starting a new business? It seems like a lot to tackle- at least initially.


Otherwise I would be interested on any feedback that you get. I've considered this option many different times. Being my own boss seems like the ultimate endeavor. But I've always been turned off with two major issues and a few more minor issues.
1. I worry about call coverage and "always" being on call. I rarely get called in at my current practice but I do enjoy being home with my family or out of town and not feeling like someone I operated on might need me. I don't tend to do well with the "mental" burden of call- no matter if I get called in or not.
2. I worry about the efficiency of a surgical practice with only one provider. When I'm in the OR, what are the staff doing? It seems like an inefficient use of staff. Somewhat related is my minor issue - I tend to be more chummy with staff and not the best at holding people to task and don't think I'd be great at hiring and firing. Not really related but I enjoy running cases by my partner(s) and also occasionally enjoy their help in the OR.

Anyway for me personally, I suspect I've talked myself out of this practice style because it's just much easier to join someone else. But I could see the appeal. Best of luck in your endeavors.

 

[OtoHNS]

I turn 40 next year and I wanted to ask any solo practioners out there (or anyone who knows people in solo practice) how long it took to ramp up his/her clinical volume.

I'm in solo practice currently, but I was initially hired as an associate by the person who started the practice.

The answer to your question is highly dependent on where you set up your practice. If you are in an underserved location, you can have patients knocking down your door on day 1 and be as busy as you want within a few months. If you want to go to a desirable location that is saturated with competitors, you may never get "fully booked", but you can still be profitable and make a decent living. I remember hearing once that it took about 35,000 population to support 1 full-time ENT. That number neglects other confounding variables like long-established referral patterns and hospital or other multispecialty practices that have a monopoly on the local PCP's and refer exclusively to their own ENTs.

When researching potential locations for your practice, I would recommend calling your competitor(s) in the morning and ask for a same-day appointment for ear pain or something else not super urgent sounding. If everyone can get you in quickly, you're most likely looking at an over-saturated area for ENT. If on the other hand, the receptionists all laugh and say the first available appointment is next February, you probably have a good opportunity.

There is also a very high time and monetary cost to starting a practice from scratch. It is sometimes possible to partner with a local hospital and have them buy your furniture and equipment depending on the situation. Otherwise, you're looking at negotiating multiple insurance contracts, a mountain of paperwork for credentialing, etc. This process can take many months, especially with government payers. While those contracts are pending, you don't get paid for seeing patients with those insurances. You can hire a practice management consultant to do all this for you but their fees run well up into the $5 figures. For your office equipment and furniture, you're also looking at a hefty cost. You have to make a decision on audio support, as well as in-office CT, allergy, cosmetic stuff, etc. It can be done, and many others have done it, but don't discount the amount of work and time necessary. I definitely think solo practice is tougher now than it was a generation ago.

One possible way to avoid all this would be to join as an associate with a 60+ year old ENT in solo practice, and take over the practice in a few years. Ideally, this would give you a nice mentor relationship for a few years and then your end goal of solo practice. In reality, things do not always go so well. If things go sour, you at least will have a reputation and patient base in the community to then venture out on your own.

 

[OtoHNS]

1. I worry about call coverage and "always" being on call. I rarely get called in at my current practice but I do enjoy being home with my family or out of town and not feeling like someone I operated on might need me. I don't tend to do well with the "mental" burden of call- no matter if I get called in or not.
2. I worry about the efficiency of a surgical practice with only one provider. When I'm in the OR, what are the staff doing? It seems like an inefficient use of staff. Somewhat related is my minor issue - I tend to be more chummy with staff and not the best at holding people to task and don't think I'd be great at hiring and firing. Not really related but I enjoy running cases by my partner(s) and also occasionally enjoy their help in the OR.

I agree with all of this. In my practice, I am on call 24/7/365 for my own patients (I do not take any ER or hospital call). I have an answering service that sends me a text for any after hours calls. I limit calls between 10p-8a for recent post-op patients only- everyone else is told to call back in the morning or go to the ER (I made this change about a year ago after a random patient I hadn't seen in 2 years called at 4am about an earache). My patients are quite respectful, and it is rare that I get a stupid call after hours. Honestly, it is fairly rare that I get any calls. For vacations, I don't schedule tonsils or anything else that is potentially high maintenance post-op during the week before I leave town. So far, this system has worked well in my practice.

Re. staffing, I usually operate 1 morning a week, and my office staff uses that as catch-up time for phone calls, procedure scheduling, paperwork, allergen mixing, etc.

I agree you do need to make hiring and firing decisions with staff. Keeping on a bad staff member is poison for the practice, and I've had to fire several over the years. Definitely not fun, but it's something you will have to do if you want to run your own practice.

 

[Otomim]

Thanks very much for all your responses. They are illuminating. I am planning to reach out to a mentor who went into PP after years in academics (though he's in a group practice) to get a better sense of whether this will be feasible and what practical steps I need to take. The pandemic is certainly not making this decision easy.

What I worry most about joining a group practice is not knowing what my senior partners/bosses are really like. I see it somewhat of a liability issue if they are not good in the OR (or as a clinician in general), make ethically questionable decisions that at first glance may be hard to detect (coding all clinic visits as level 4 or 5 for example -- which I have heard of), or design the practice that biases finances and workflow in their favor. I don't at all mean to sound high and mighty here, but I have had my fair share of referrals from community ENTs who I feel made some questionable decisions and I worry about partnering up with someone that may not be the best clinically or someone that may take advantage of a newbie like me who has just ventured into the private world. We've all worked with colleagues in the past who cut corners or took advantage of situations in their favor, and at times it's not easily apparent until you actually start working with them -- and I would hate to waste years to find out that the practice I joined sucks. I also heard about a whole practice getting sued after a patient suffered complications under one of its partners -- definitely would want to avoid something like this.

In any case, thank you all for all your advice. If there are any resources out there that you can point me to, I would love to hear about. Can private message me if you wish.

Thanks again.