Independent practice vs. salaried position

[DrJosephKim]

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These days, many residents who are preparing to finish their training and contemplating several employment models. We have the traditional private practice model that used to represent the vast majority of physicians. Now, we're seeing many more physicians embrace a salaried model where their income is not dependent on how many patients they see, how many procedures they perform, etc.

Which employment model do you think you'll pursue when you complete your training? Independent practice or salaried?

 

[mlw03]

Salary almost certainly, but that's not much of a choice for my subspecialty.

 

[rickrick2012]

Salary almost certainly, but that's not much of a choice for my subspecialty.

I guess it is really depends on your personality.
Personally, I think it is a necessity: teach business aspects in the school too!

 

[sia_simba]

Big group practice. =)

days of solo practice is out the door, pending your specific locations. But in major cities, its better with large group practice.

Working for hospital based on salary, you can be scutted out.

Working for hospital with OVERTIME and full malpractice coverage = BEST !!!!

However, if you're working for somebody else, you also risk being fired the very next day!

I have the great pleasure of

1. Working for hospital with OVERTIME and full malpractice coverage including my group private practice = super BEST !!!!!

 

[Shoushu]

I have the great pleasure of

1. Working for hospital with OVERTIME and full malpractice coverage including my group private practice = super BEST !!!!!

How do you reconcile the two? How many hours do you spend at each place?

 

[PharmaTope]

These days, many residents who are preparing to finish their training and contemplating several employment models. We have the traditional private practice model that used to represent the vast majority of physicians. Now, we're seeing many more physicians embrace a salaried model where their income is not dependent on how many patients they see, how many procedures they perform, etc.

Which employment model do you think you'll pursue when you complete your training? Independent practice or salaried?

Becoming SALARIED is the very worst decision you can possibly make. Reason is, hospitals buy out practices locally. They try to build their own "network of providers" When this happens, sometimes their group becomes so large it is hard to compete against them. You become an employee of the hospital that can dictate to you EVERYTHING. Once you are salaried employee, you will be victimized by the hospital administration.

I encourage people to do their best to stay in independent practice if possible. Look at the pharmacy world. Pharmacists elected to show up and collect a salary. They lost power and fail to compete with bigger corporations.

 

[jdh71]

I'm hoping to work with a group practice someday - hopefully with enough to make call and consult coverage tolerable.

I would avoid being a hospital employee like I avoid syphilis. The bottom line is when you work in a system where you can be used and abused, you will be. The only way to have any real leverage is to stay as independent as possible.

 

[PharmaTope]

I'm hoping to work with a group practice someday - hopefully with enough to make call and consult coverage tolerable.

I would avoid being a hospital employee like I avoid syphilis. The bottom line is when you work in a system where you can be used and abused, you will be. The only way to have any real leverage is to stay as independent as possible.

at least a lot of physicians get this. a lot of older guys have been selling their practice to the hospital to avoid anything else. problem is they make the hospital stronger and give it way more leverage over the future physicians.

it is scary, esp if you work in a a work at will state. hospital can just terminate you for any reason and you cannot sue etc. very scary

 

[Sneezing]

Independent Practice

Through medical school I've seen salaried and hospital owned physicians. Its one notch above being a mid level. How you practice, who you work with and what you can change are all dictated to you.

There were many reasons why I became a physician but independence and freedom were one of the largest reasons. By being salaried or integrated in large group practices you give up that autonomy. No thanks. One of the best things about being a professional is the ability to make your own schedule, charge what you are worth, and control your work environment of who is there and what your place's work ethic will be. The most important is the ability to truly advocate for your patient in a true patient-doctor relationship rather than being a minion of your ACO, HMO, group practice, or mega health system.

If we continue the trend of becoming salaried and joining large groups etc away from the independent practice, we will lose greatest bargaining power behind being a physician. Medicine itself will be nothing more than another bureaucratic industry of forms and patients will lose out.

 

[TexasPhysician]

Both group and independent. Get benefits from a group/salary position and make better income elsewhere.

 

[oldbearprofessor]

Through medical school I've seen salaried and hospital owned physicians. Its one notch above being a mid level. How you practice, who you work with and what you can change are all dictated to you.

I've been a salaried medical school faculty for more than 2 decades. It is by far my preference. I would not wish nor have I ever wished to be involved in the business side of medicine. I realize this is upsetting to some that there are physicians who prefer to be employees, but we are out there. Lots of us for lots of reasons. There are pros and cons to this approach for a pediatric specialist, but, none of them make me feel like I have no say in how I practice, who I work with or what I can change. That is simply an inaccurate description of my salaried academic faculty position.

Just thought I'd present the other side since the anti-salaried position seems to have dominated this thread. There is another perspective, go ask folks who like the salaried model why they like it.

 

[QofQuimica]

I've been a salaried medical school faculty for more than 2 decades. It is by far my preference. I would not wish nor have I ever wished to be involved in the business side of medicine. I realize this is upsetting to some that there are physicians who prefer to be employees, but we are out there. Lots of us for lots of reasons. There are pros and cons to this approach for a pediatric specialist, but, none of them make me feel like I have no say in how I practice, who I work with or what I can change. That is simply an inaccurate description of my salaried academic faculty position.

Just thought I'd present the other side since the anti-salaried position seems to have dominated this thread. There is another perspective, go ask folks who like the salaried model why they like it.

OBP, these folks are almost certainly talking about being clinicians in community practice/hospitals, not academics working as faculty in teaching centers.

FWIW, I am going to be a salaried academic subspecialist too. A lot of these careers for subspecialists aren't really even possible outside of academic centers. In my case, the only way I could have a private practice would be if I did something that was only tangentially related to what I'm being trained to do, such as being a professional expert witness. I might also be able to go into industry, but that has its own whole set of problems relating to working for The Man. 😉

 

[Doctor Bagel]

I used to think salaried all the way, but in my field, I think being an independent practitioner is relatively doable. We've got low overhead, and being on my own might free me up to do more psychotherapy type of work if that's what I want to do. So I'm still not sure. I like knowing this whole private practice world is out there, though.

I've already scratched off academics, the VA, and the state hospital from my list of possible future employers, btw.

 

[oldbearprofessor]

OBP, these folks are almost certainly talking about being clinicians in community practice/hospitals, not academics working as faculty in teaching centers.

Why does that matter? Neonatologists who are "clinicians in community practice/hospitals" often are salaried as part of academic medical groups and often are not-salaried. A new grad has a free choice to make. The issues are the same as are the choices whether it is in the med center (where one can often work in private practice in children's and university affiliated hospitals) or community hospitals. Many choose the salaried route for lots of good reasons that don't include selling out or being just above midlevels as was suggested by some on this thread.

 

[Doctor Bagel]

Why does that matter? Neonatologists who are "clinicians in community practice/hospitals" often are salaried as part of academic medical groups and often are not-salaried. A new grad has a free choice to make. The issues are the same as are the choices whether it is in the med center (where one can often work in private practice in children's and university affiliated hospitals) or community hospitals. Many choose the salaried route for lots of good reasons that don't include selling out or being just above midlevels as was suggested by some on this thread.

There are definitely lots of advantages to having salaries. You know how much you'll make, and usually you get more help with things like insurance and other benefits, which are huge. You're not a sucker because you like getting a guaranteed salary with guaranteed benefits. 🙂

I think a lot of the negativity in this thread stems from seeing all the dysfunctional systems that we work with as medical students and residents. Resident clinics usually suck. Academic attendings appear willing to put up with tons of non-ideal stuff in exchange for teaching, a sense of duty (?) and research support. The VA = a big bureaucracy. Lots of private hospitalists are miserable, etc.. So yeah, we idealize not working in these symptoms and maybe act overly dismissive of the benefits of these systems for people who aren't at the bottom of the totem pole (us).

 

[QofQuimica]

Why does that matter? Neonatologists who are "clinicians in community practice/hospitals" often are salaried as part of academic medical groups and often are not-salaried. A new grad has a free choice to make. The issues are the same as are the choices whether it is in the med center (where one can often work in private practice in children's and university affiliated hospitals) or community hospitals. Many choose the salaried route for lots of good reasons that don't include selling out or being just above midlevels as was suggested by some on this thread.

It matters because the work is often not purely clinical, and as such, other factors come into play besides what the anti-salary position posters are considering. For example, an NIH-funded researcher who is a renowned expert in their area of specialty is not going to be fired on a whim of the hospital brass. Even an "average" academic physician is not going to be fired at whim if they are a tenured professor.

As for colleagues who are purely clinical and debating between being salaried versus independent, like you suggested, there are obviously pros and cons to each employment model. I agree with you that there's not any reason to disparage either choice. What works best for one person doesn't necessarily work best for another, and even for the same person, what works best may change over time. A person may want to have a solo or small group practice at age 30 or 40, but then find that being salaried is a lot more tenable at age 60 or 70.

Personally, my retirement plan is to be an ethicist. 🙂

 

[PharmaTope]

"hello doctor, this is the administration you work for, we think that the haircut you have/choice of facial hair does not coincide with our institution goals, please correct these immediately, this is your FIRST WARNING. any other writeups on this will result in termination. have a great day..."


"hello doctor, i know you saw 40 patients today and are tired, but we want to promote a happy feeling to our patients here at the hospital. so we want all our doctors to wear a XYZ Hospital FLAIR badge to promote a happy unity here. we also want all physicians to ask the patients "how is your dinner? can i do anything to make your stay/food better here?" we want our patients knowing that their doctor solves ALL PROBLEMS not just their medical problems"

"hello doctor, we are cutting back on physicians now, we want you to cross cover these hospitals. i know tomorrow was your day off, but we want you to do this for an undetermined amount of time. yes, we know you are SALARY, so you will not have any sort of pay increase nor will you get additional days off or vacation time"

signed

The Administration you have become a SALARY EXEMPT EMPLOYEE AT

good luck with that, prob the WORST thing you can ever sign up to do. look at hospitalists. they hate it

 

[jdh71]

"hello doctor, this is the administration you work for, we think that the haircut you have/choice of facial hair does not coincide with our institution goals, please correct these immediately, this is your FIRST WARNING. any other writeups on this will result in termination. have a great day..."


"hello doctor, i know you saw 40 patients today and are tired, but we want to promote a happy feeling to our patients here at the hospital. so we want all our doctors to wear a XYZ Hospital FLAIR badge to promote a happy unity here. we also want all physicians to ask the patients "how is your dinner? can i do anything to make your stay/food better here?" we want our patients knowing that their doctor solves ALL PROBLEMS not just their medical problems"

"hello doctor, we are cutting back on physicians now, we want you to cross cover these hospitals. i know tomorrow was your day off, but we want you to do this for an undetermined amount of time. yes, we know you are SALARY, so you will not have any sort of pay increase nor will you get additional days off or vacation time"

signed

The Administration you have become a SALARY EXEMPT EMPLOYEE AT

good luck with that, prob the WORST thing you can ever sign up to do. look at hospitalists. they hate it

agreed

academic gigs are a little different, with all due respect to OBP, but still not the same for us new guys coming out of training. If you're an established guy, especially if you hold tenure, are super-sub-specialized your position is a little different.

 

[lowbudget]

I'm salaried, primary care. Not ideal, but I'm going to put myself in the pro-salary camp for now. My background is finance. From what I've seen, in my world, there is a lot of business risk right now for private practice; and no clarity on what the payoff is on the back side. Health care reform has helped me a little bit from a volume standpoint, but my group still struggle with overhead, collections, and reimbursement rates. I need 2014 to come with ACO's up and running, but there is too much uncertainty regarding the Supreme Court and Republicans.

There are waves of salaried physicians where I am as hospitals (like back in the 90's with HMO's...) are buying up practices and hiring employed physicians (primary care, cardiology, orthopedics) to align themselves for ACO's and bundled payments to capitalize on the pre-hospital phase.

Salaried physicians give up control. That's a good or bad thing; I don't know.

My prediction is that in my little bubble, medicine will become more big box, shift workers, with no control. Physicians will be less vested in their patients (other than caring for target markers that will be paid for performance, like A1c's, BP's); so medicine will become more and more impersonal and less caring.

I see that as an opportunity. I went salary when all my classmates were going into their own practice. And, now that everyone is going salary, I'm trying to figure out when to go private practice. I think there's an opportunity/niche for personal, small practices. The question is, can you manage your expenses and can you negotiate good reimbursement rates?

Those questions can only be answered through health care reform, and since political risk is a very hard risk to predict and quantify, I'm hiding out in a salary position for the time being until I have a little bit more clarity and predictability before I can make the move to invest in a private practice.

Private practice is like running a small business, like a convenient store, an internet start-up, coffee shop, or gas station. You gotta be willing to put your life into nurturing this Mom-&-Pop deal (whether you're in a small group or big group) in order for it to be successful.

 

[Sneezing]

There are waves of salaried physicians where I am as hospitals (like back in the 90's with HMO's...) are buying up practices and hiring employed physicians (primary care, cardiology, orthopedics) to align themselves for ACO's and bundled payments to capitalize on the pre-hospital phase.

Salaried physicians give up control. That's a good or bad thing; I don't know.

My prediction is that in my little bubble, medicine will become more big box, shift workers, with no control. Physicians will be less vested in their patients (other than caring for target markers that will be paid for performance, like A1c's, BP's); so medicine will become more and more impersonal and less caring.

This trend is what ticks me off and I see giving up control as a bad thing for both patients and physicians.

 

[PharmaTope]

This trend is what ticks me off and I see giving up control as a bad thing for both patients and physicians.

i agree. pay for performance is a scary situation. it really doesnt take the patient into account. plus your pay can be screwed bc someone is noncompliant with their meds/lifestyle.... and how many patients are like that? a fair number. last thing you want is hospitals having power over the physician