Retina: Solo Practice vs Group Practice

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ayeball

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Looking for some additional guidance as July feels to be approaching faster than ever. Over the past few years, I've been very inspired by the two solo practice startup blogs, and I've gone back and forth debating the merits of each practice type (solo vs group). I was wondering if people on here could speak to some of the advantages and disadvantages of each, particularly with respect to retina and where it differs from comp or other subspecialities.

First, my wife and I are from a rural area, and after our experience with "homeschooling" during COVID, we came to realize that it is not something that would be out of the question for us to pursue were we to return to an area without great schools. So, though it would not necessarily be our first choice, we are open to moving to an undersaturated part of the country and starting a solo practice (I'm aware that it would be a lot of work, but there appears to be a lot of support in place, particularly with that of @schistosomiasis's solo practice startup venture).

There are many pros to joining a group practice, such as a starting salary, a pre-existing framework to plug into, shared call and vacation coverage, economies of scale/shared equipment overhead, etc. The big con that hangs over my head is the worry about being churned / practice being sold to PE before I make partner. Were the latter not an issue, I would probably be entirely focused on group practices.

There are also numerous pros to solo practice, the foremost being complete independence to run the practice as I see fit / no potential conflicts when it comes to decisions that affect the practice. One challenge in my mind is the call situation.

My big question is regarding the financial implications between the two. Moving to an undersaturated part of the country, I would probably pick a place where I was the only retina surgeon around, or close to it. Therefore, it wouldn't make sense to build and own a practice ASC, if I was only operating once per week. So, it would seem like this income stream would most likely be closed to me. Is this a big issue? Also, there is the fact that I would be buying all of the expensive equipment for my use only (to what extent do busy group practices see savings/profit generation via equipment sharing?).

Roughly speaking, assuming an equal level of productivity, is there a significant difference in terms of compensation (at the average and above average level) between the two practice models? Put another way, what kinds of financial opportunities might a solo practice miss out on / what kinds of financial penalties might they face? And, to what extent does the number of partners affect compensation: is a two-person retina practice, for example, significantly more profitable than a solo retina practice? Is there a point at which (say, at 2, 3, 4, 5, or 6 partners) profitability increases sharply, or, faces diminishing returns due to inefficiencies stemming from institutional complexity?

Finally, there are multi-specialty practices. This potentially deserves its own thread, but any thoughts about multi-specialty practices with respect to all of the points above are welcome as well.

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For now, I’m not answering your other points because I feel like this is important to say. Practicing as a solo retina doc would be very difficult, time wise. You’d be living the lifestyle of a general surgeon rather than an ophthalmologist.

it can be done but you better know what you are getting into. When I first started, it was just me and another retina doc. Every other night, or every other week, call is rough.

With retina, if you are seeing 50+ pts/day in clinic, and then a mac on RD comes in, when do you think you’ll be doing that case? You going to cancel your 50 pt day today, or the next day? Where are you now going to put all of those pts? This surgery will be after hours, at the hospital, whenever the general and ortho surgeons complete their cases. So you’ll be operating late and then turn around and start your 50+ pt day in clinic again the next day. And God help you if you have 3-4 mac on RDs come in the same day (it happens). Also, retina deals with a lot of other same day “emergencies”…… .retinal tears, endo, dropped lenses, etc….these also must be added to an already busy day and dealt with in a timely fashion. When you are solo, you are the one trying to figure out where to put all these pts and wheee to do all these emergency add on cases. And forget you starting an ASC as a solo doc. It can be done but you’ll hear a loud sucking noise coming out of your wallet. Multiple retina docs, yes. One retina doc, NO!

When you have partners, you don’t have to have all these concerns. in my group, there are multiple surgeons, and we operate five days per week at an eye only ASC. If I have 1-2 mac on RDs come into my office, I don’t worry about when or where I will do them. I add it to one of my partners the next day, and it gets done. They do the same with me. We have a great life and I’ve not been in the OR after 5:00 in years!!!

Just food for thought!
 
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Thanks so much for explaining this aspect in detail. I knew it would be rough, but not this rough.
 
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I would not rule out a one doctor retina practice except that I am not in retina.

Ideally, it would be a one doctor retina practice that grows to two. When the practice grows to too many doctors, there then becomes a full time administrator, who is usually not as dedicated as a doctor unless it's the doctor's wife (could be husband) who also has good business sense.
 
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Definitely would be great to grow from one to two (or more) docs. I’ve seen it done. But, be prepared for a rough life until you can find that second doc.

Also, Doc320 brings up another good point about a practice administrator. You’ll definitely need one of these people. The world of billing, and keeping up with all the stupid regulations (ie, MIPS) is insane and would take up an extraordinary amount of your time (in addition to your clinical duties). Just handling the drug inventory can be a nightmare. Lucentis and Eylea are NOT cheap so, if you are doing 100s of these every week or two, you do not want to screw up inventory or it’s going to cost A LOT of money
 
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RetinaDude makes good points. But I’d get more opinions from retina specialists who’ve done it. I know several solo retina specialists in saturated markets. They’re doing fine. Because they can keep overhead low, they don’t need to see 50+ patients a day. They’re doing very well financially seeing 20 patients a day and if they don’t have the time to handle a case, they send them to a friend at the nearest academic center.

Strangely enough, based on what I’m hearing, it may actually be easier to pull off solo retina in a less remote area.
 
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With retina, if you are seeing 50+ pts/day in clinic, and then a mac on RD comes in, when do you think you’ll be doing that case? You going to cancel your 50 pt day today, or the next day? Where are you now going to put all of those pts? This surgery will be after hours, at the hospital, whenever the general and ortho surgeons complete their cases. So you’ll be operating late and then turn around and start your 50+ pt day in clinic again the next day. And God help you if you have 3-4 mac on RDs come in the same day (it happens). Also, retina deals with a lot of other same day “emergencies”…… .retinal tears, endo, dropped lenses, etc….these also must be added to an already busy day and dealt with in a timely fashion. When you are solo, you are the one trying to figure out where to put all these pts and wheee to do all these emergency add on cases. And forget you starting an ASC as a solo doc. It can be done but you’ll hear a loud sucking noise coming out of your wallet. Multiple retina docs, yes. One retina doc, NO!

When you have partners, you don’t have to have all these concerns. in my group, there are multiple surgeons, and we operate five days per week at an eye only ASC. If I have 1-2 mac on RDs come into my office, I don’t worry about when or where I will do them. I add it to one of my partners the next day, and it gets done. They do the same with me. We have a great life and I’ve not been in the OR after 5:00 in years!!!

Just food for thought!
This is definitely how I would do things if I were a retina specialist.

There's a certain very large group of retina specialist out east that sold out to PE a few years ago. You know, the one where you have to have ivy league credentials to get a job there. Apparently they all have to go in to do their own RD's after hours rather than sharing with one of their other 30 colleagues. I'm told that's the culture. What gives?
 
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If someone was to open up a solo retina practice, I would specifically advise them NOT to do it in a rural location where there aren’t any other retina docs. Find an area where there are a few other docs, either solo or small groups, that will are cordial/ collaborative and are willing to help each other out on call. Remember: most people want to help each other rather than be sucked into private equity. Many of my solo retina friends have good lifestyles with this approach. Some of my friends have difficulty to find helpful colleagues and are more stressed as a result, so RetinaDude is absolutely real in some but not all instances.

All my friends that are in solo retina are doing very well financially, but don’t go solo for the money. Do it for the independence. They went solo because the DIDN’T want to see 50 patients per day. One of my friends is part time so she can actually watch her kids grow up.

Starting an ASC can be a very profitable venture (or not) even with just a few busy surgeons, or even starting with doctors in other non-ophtho fields. But you’re kidding yourself if you think you need to do so to become independently wealthy. If your lifestyle depends on ASC income, you have a spending problem, not an earning problem,. If you don’t like your current surgery setup (the hospital takes a half hour to turn over cases and doesn’t give you block time) then you should start an ASC. I spend enough bandwidth running my practice that I don’t need the headaches of running or being involved in another business. Some of my close friends enjoy this type of thing, and also do well. But not me.
 
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About starting the ASC...you'll also need some busy cataract surgeons to make that profitable. Retina is not the most profitable in the ASC setting (some contracts are better than others) so factor that in when you think about location. Retina solo to me is tough. I'm in a large retina practice and appreciate the flexibility of adding cases on to my partners' OR days instead of evening cases at the hospital. The hardest part to me would be the drugs, billing, pre-auths, etc. Doable for sure, but very daunting to take on. You can control your schedules to some extent in a retina practice, you don't have to see 50+ patients but honestly, even with a bunch of us a lot of patients who need to be seen every 4-6 weeks for injections. But with an efficient set up, scribes, etc still home by 5 and feel like I have reasonable conversations with patients.
 
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For now, I’m not answering your other points because I feel like this is important to say. Practicing as a solo retina doc would be very difficult, time wise. You’d be living the lifestyle of a general surgeon rather than an ophthalmologist.

it can be done but you better know what you are getting into. When I first started, it was just me and another retina doc. Every other night, or every other week, call is rough.

With retina, if you are seeing 50+ pts/day in clinic, and then a mac on RD comes in, when do you think you’ll be doing that case? You going to cancel your 50 pt day today, or the next day? Where are you now going to put all of those pts? This surgery will be after hours, at the hospital, whenever the general and ortho surgeons complete their cases. So you’ll be operating late and then turn around and start your 50+ pt day in clinic again the next day. And God help you if you have 3-4 mac on RDs come in the same day (it happens). Also, retina deals with a lot of other same day “emergencies”…… .retinal tears, endo, dropped lenses, etc….these also must be added to an already busy day and dealt with in a timely fashion. When you are solo, you are the one trying to figure out where to put all these pts and wheee to do all these emergency add on cases. And forget you starting an ASC as a solo doc. It can be done but you’ll hear a loud sucking noise coming out of your wallet. Multiple retina docs, yes. One retina doc, NO!

When you have partners, you don’t have to have all these concerns. in my group, there are multiple surgeons, and we operate five days per week at an eye only ASC. If I have 1-2 mac on RDs come into my office, I don’t worry about when or where I will do them. I add it to one of my partners the next day, and it gets done. They do the same with me. We have a great life and I’ve not been in the OR after 5:00 in years!!!

Just food for thought!
I'm puzzled. If several mac on RDs and assorted other emergencies a day are coming into clinic, why are you scheduling 50+ patients a day? Shouldn't there by some flexibility in the schedule to accommodate that? Maybe go with 40+ patients a day in clinic.
 
For now, I’m not answering your other points because I feel like this is important to say. Practicing as a solo retina doc would be very difficult, time wise. You’d be living the lifestyle of a general surgeon rather than an ophthalmologist.

it can be done but you better know what you are getting into. When I first started, it was just me and another retina doc. Every other night, or every other week, call is rough.

With retina, if you are seeing 50+ pts/day in clinic, and then a mac on RD comes in, when do you think you’ll be doing that case? You going to cancel your 50 pt day today, or the next day? Where are you now going to put all of those pts? This surgery will be after hours, at the hospital, whenever the general and ortho surgeons complete their cases. So you’ll be operating late and then turn around and start your 50+ pt day in clinic again the next day. And God help you if you have 3-4 mac on RDs come in the same day (it happens). Also, retina deals with a lot of other same day “emergencies”…… .retinal tears, endo, dropped lenses, etc….these also must be added to an already busy day and dealt with in a timely fashion. When you are solo, you are the one trying to figure out where to put all these pts and wheee to do all these emergency add on cases. And forget you starting an ASC as a solo doc. It can be done but you’ll hear a loud sucking noise coming out of your wallet. Multiple retina docs, yes. One retina doc, NO!

When you have partners, you don’t have to have all these concerns. in my group, there are multiple surgeons, and we operate five days per week at an eye only ASC. If I have 1-2 mac on RDs come into my office, I don’t worry about when or where I will do them. I add it to one of my partners the next day, and it gets done. They do the same with me. We have a great life and I’ve not been in the OR after 5:00 in years!!!

Just food for thought!
@RetinaDude how do referring ophthalmologists perceive a multi specialty group where you are?
In my region general Opthos fear (unnecessarily usually) that if they refer someone to the retina specialist, the practice will keep or "steal" the patient for their general eye care as well.

@ayeball my husband's practice collaborated with a new retina specialist for a while, giving him 1 1/2 clinic days a week in his office to see retina patients. His patients loved it because they didn't have to drive to a different town to see someone, they could get care in the office they were accustomed to. The retina specialist did this for a couple of years while building up his practice in his own separate office, then he got so busy he was unable to keep coming to my husband's office. Gotta say we miss him but it was a good collaboration for both of them.
 
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I'm puzzled. If several mac on RDs and assorted other emergencies a day are coming into clinic, why are you scheduling 50+ patients a day? Shouldn't there by some flexibility in the schedule to accommodate that? Maybe go with 40+ patients a day in clinic.
If we don’t see these pts, where are they going to go? It would be marvelous to only see 30 pts per day but the need is too great. Within a retina practice, you are mainly dealing with elderly pts with severe vision problems, or younger people with severe vision problems. It’s not easy for them to hop in a car and drive 2-4 hours away to see another retina doc because our office is too busy. And, as 4424 commented, the majority of these pts are requiring injections on a set schedule (or mostly set), so you can’t just say “ok, I’ve got 40 pts today so tell the other pts, the one’s who are supposed to get injections today, that we are full and they will just have to go blind”.
 
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@wysdoc, we are extremely careful about insisting all referrals go back to the referring doc from which they originated. Also, we make it very clear, we are only providing retina care and they must see their regular eye doc for everything else
 
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@wysdoc, we are extremely careful about insisting all referrals go back to the referring doc from which they originated. Also, we make it very clear, we are only providing retina care and they must see their regular eye doc for everything else
Likewise, thanks.
 
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@wysdoc, we are extremely careful about insisting all referrals go back to the referring doc from which they originated. Also, we make it very clear, we are only providing retina care and they must see their regular eye doc for everything else
I’ll second that. I make it a point that anything non-retina related goes back to the referring physician (especially dry eyes!)
 
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I would echo a lot of the above, not a believer in solo unless there’s a lot helping you.

-Tougher lifestyle. Definitely do not be the ONLY retina person for 100 miles or you’re never leaving home
-Similarly, may be tough to find solo providers that are willing to potentially give you a piece of the referrals from community docs to split call
-You need an OR. An ASC out of the gate is off the table. So you need a hospital most likely, plus justifying to them the investment they would put in with staff and equipment, so absolutely try to find an area with someone already practicing. Hard part is sometimes there are exclusive practice rights for an already established group/doc in hospital by-laws
-You need serious, and I mean serious, business sense. We get minimal business education in training, so unless you grab some amazing help or are a natural at running a corporation, you’re working worse than residency hours with all the behind the scenes stuff for a while
 
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