Solo practice out of residency?

[Wildfish89]

Hello,

Current PGY-4 and trying to decide what to do after training. I am leaning towards going into private practice and I'm contemplating starting my own practice vs. joining another practice.

Although the idea of going out on my own is scary and does entail some risk (taking out a loan to start a practice vs. stepping into a high paying job) I really like the idea of having my own business and being the primary decision maker.

However, some have suggested to me that it would be better to join an established group to get some mentorship and learn a bit more about the business side of medicine before venturing out on my own. This would also enable me to save up some money from my attending salary to use to start my own practice. This seems reasonable except that I don't like the idea of delaying my ultimate goal, especially given that my life to this point has been an orgy of delayed gratification.

Appreciate any thoughts/advice from my more seasoned colleagues.

---

Members don't see this ad.

 

[Angler]

However, some have suggested to me that it would be better to join an established group to get some mentorship and learn a bit more about the business side of medicine before venturing out on my own. This would also enable me to save up some money from my attending salary to use to start my own practice

This.

These days managing a practice is a full time job, especially difficult when you're learning as you go. On top of that, you actually have to practice medicine, which is a full time job. It's not impossible, but you'll need the help of someone/something you trust. Read contracts very carefully (in fact get an atty to review it; observe non-compete clauses).

 

[anonperson]

Hello,

Current PGY-4 and trying to decide what to do after training. I am leaning towards going into private practice and I'm contemplating starting my own practice vs. joining another practice.

Although the idea of going out on my own is scary and does entail some risk (taking out a loan to start a practice vs. stepping into a high paying job) I really like the idea of having my own business and being the primary decision maker.

However, some have suggested to me that it would be better to join an established group to get some mentorship and learn a bit more about the business side of medicine before venturing out on my own. This would also enable me to save up some money from my attending salary to use to start my own practice. This seems reasonable except that I don't like the idea of delaying my ultimate goal, especially given that my life to this point has been an orgy of delayed gratification.

Appreciate any thoughts/advice from my more seasoned colleagues.

This is not unique to ENT but some things to consider. These were my experiences coming out of fellowship from a semi surgical specialty.

This is not meant to dissuade you from going solo but just consider some things:

If solo:
-If you run into tough cases, who will help you out? Either in the OR or bouncing ideas for a difficult patient from the office.

-I'm guessing you would have hospital privileges. Who will be your designated back up? Most hospitals require this during the application period and when you renew.

-Similarly, if you are solo, who will cover your patients when you are on vacation? Phone calls, post op issues etc.

- Is the area you are practicing very underserved regarding your specialty? If there are others, do they play nice? Are they collegial even with their competition?

Just a quick example. I was on my way to clinic when I was called by the OR. They asked if I would come in as a local GYN was doing a hysterectomy and was worried about the ureter. I thought it would be a quick cystoscopy and I could go with minimal delay. Ended up being a complete ureteral transection and me needing to do a reimplantation. Screwed up my morning and had to reschedule a bunch of patients.

Even though this doc rarely refers patients to me I didn't want to leave him hanging or let the patient suffer. Was a professional courtesy.

-Is there a local health system or regional that could encroach at some point and eat into your referrals? Unfortunately, these large health systems are aggressively expanding and have numerous satellites that can hurt private practice docs.
--------------------------------------------------------
If going solo, you will need to hire staff, which means managing people and knowing employment laws.

A friend of mine is a PCP with his own practice. Had to deal with a MA making a sexual harassment claim against another employee. Was a big pain to deal with.

Similarly, if you want to fire people, you will typically need to know the laws and procedures to avoid wrongful termination lawsuits. You can contract out the HR process but it is something to think about.

You will need to get on insurance panels, join IPAs etc. This will take some time. Insurance companies can drag their feet in this regard but it is location and specialty dependent.
_--------------------------------------------------------------

Just some things to think about.

It can be very lucrative and rewarding to have your own practice but it will take a fair amount of work.

Unfortunately the government has completely disincentived private practice medicine and is throwing money at these health systems.

 

[Wildfish89]

This.

These days managing a practice is a full time job, especially difficult when you're learning as you go. On top of that, you actually have to practice medicine, which is a full time job. It's not impossible, but you'll need the help of someone/something you trust. Read contracts very carefully (in fact get an atty to review it; observe non-compete clauses).

Appreciate that advice! There are a lot of things with which I am not super familiar, particularly regarding clinic optimization so it does make sense to get some exposure first while I continue to develop my medical skills.

If solo:
-If you run into tough cases, who will help you out? Either in the OR or bouncing ideas for a difficult patient from the office.

My thought was to speak to mentors from residency before undertaking such cases. Intraoperatively would be challenging, to your point, though.

-I'm guessing you would have hospital privileges. Who will be your designated back up? Most hospitals require this during the application period and when you renew.

This is good insight, I did not know that a designated backup physician was required.

-Similarly, if you are solo, who will cover your patients when you are on vacation? Phone calls, post op issues etc.

Would try to arrange operating to avoid doing cases most likely to incur complications (to the extent that possible) right before vacation. Otherwise would let my patients know ahead of time I will be away. I am currently at a large academic center and we see a fair amount of random private practice patients who can't see their main person for whatever reason. Not ideal but its not the end of the world.

- Is the area you are practicing very underserved regarding your specialty? If there are others, do they play nice? Are they collegial even with their competition?

Just a quick example. I was on my way to clinic when I was called by the OR. They asked if I would come in as a local GYN was doing a hysterectomy and was worried about the ureter. I thought it would be a quick cystoscopy and I could go with minimal delay. Ended up being a complete ureteral transection and me needing to do a reimplantation. Screwed up my morning and had to reschedule a bunch of patients.

Even though this doc rarely refers patients to me I didn't want to leave him hanging or let the patient suffer. Was a professional courtesy.

-Is there a local health system or regional that could encroach at some point and eat into your referrals? Unfortunately, these large health systems are aggressively expanding and have numerous satellites that can hurt private practice docs.

These are good insights, I haven't narrowed down a location but I'm sure I would obviously heavily consider the competition landscape. It was very nice of you to help that patient.

--------------------------------------------------------
If going solo, you will need to hire staff, which means managing people and knowing employment laws.

A friend of mine is a PCP with his own practice. Had to deal with a MA making a sexual harassment claim against another employee. Was a big pain to deal with.

Similarly, if you want to fire people, you will typically need to know the laws and procedures to avoid wrongful termination lawsuits. You can contract out the HR process but it is something to think about.

You will need to get on insurance panels, join IPAs etc. This will take some time. Insurance companies can drag their feet in this regard but it is location and specialty dependent.
_--------------------------------------------------------------

Just some things to think about.

It can be very lucrative and rewarding to have your own practice but it will take a fair amount of work.

Unfortunately the government has completely disincentived private practice medicine and is throwing money at these health systems.

Yeah it's like running a business, there are definitely some challenging aspects from which one is shielded when one is at a larger institution, but makes it more rewarding, I think.

I really appreciate your thoughts!

 

[wysdoc]

There's an SDN member who posts his story about starting his own practice, you might enjoy reading opened-my-own-practice-an-update-year-2-5.1435610

 

[Pir8DeacDoc]

This is not unique to ENT but some things to consider. These were my experiences coming out of fellowship from a semi surgical specialty.

This is not meant to dissuade you from going solo but just consider some things:

If solo:
-If you run into tough cases, who will help you out? Either in the OR or bouncing ideas for a difficult patient from the office.

-I'm guessing you would have hospital privileges. Who will be your designated back up? Most hospitals require this during the application period and when you renew.

-Similarly, if you are solo, who will cover your patients when you are on vacation? Phone calls, post op issues etc.

- Is the area you are practicing very underserved regarding your specialty? If there are others, do they play nice? Are they collegial even with their competition?

Just a quick example. I was on my way to clinic when I was called by the OR. They asked if I would come in as a local GYN was doing a hysterectomy and was worried about the ureter. I thought it would be a quick cystoscopy and I could go with minimal delay. Ended up being a complete ureteral transection and me needing to do a reimplantation. Screwed up my morning and had to reschedule a bunch of patients.

Even though this doc rarely refers patients to me I didn't want to leave him hanging or let the patient suffer. Was a professional courtesy.

-Is there a local health system or regional that could encroach at some point and eat into your referrals? Unfortunately, these large health systems are aggressively expanding and have numerous satellites that can hurt private practice docs.
--------------------------------------------------------
If going solo, you will need to hire staff, which means managing people and knowing employment laws.

A friend of mine is a PCP with his own practice. Had to deal with a MA making a sexual harassment claim against another employee. Was a big pain to deal with.

Similarly, if you want to fire people, you will typically need to know the laws and procedures to avoid wrongful termination lawsuits. You can contract out the HR process but it is something to think about.

You will need to get on insurance panels, join IPAs etc. This will take some time. Insurance companies can drag their feet in this regard but it is location and specialty dependent.
_--------------------------------------------------------------

Just some things to think about.

It can be very lucrative and rewarding to have your own practice but it will take a fair amount of work.

Unfortunately the government has completely disincentived private practice medicine and is throwing money at these health systems.

This is all excellent.

I will echo some of it.
-What's the call arrangement? If you're not on call and a patient of yours has an issue, what's the plan? What if you're out of town?
- Despite how you feel at the end of residency, there's a transition to independent practice. Cases are harder by yourself and without a thousand people around to help if something comes up. This is true of the office and the OR. Sometimes cases are just bigger and you need another set of hands- i.e. big goiter etc. Do you want to do those cases? Or just plan to refer?
- do you know anything about leadership and staff management? Do you want to? How much will you pay them? When will they get a bonus? When will they get a raise? how much vacation? Do they "work" when you are out of town?

Best wishes as you survey your options. For me, personally, I enjoy sharing an office with other doctors. We laugh, we commiserate, we help each other out, we share call. When I walk out of the office on Friday if I'm not on call- I'm 100% free of responsibility. For me, that's damn near priceless.

 

[Wordead]

If your goal is to primary decision maker, you can have that if you join an established practice that isn't huge. A large chunk of private practices are run by people on the older end of the spectrum or solo practitioners and once they retire someone else is going to have to take over. You could have your bridge period of learning and then take over leadership of the practice.

Also make sure you like running your own business, not just the IDEA of running your own business. It's not for the faint of heart. Do you understand how to dig into a P+L statement, negotiate with insurance, deal with HR issues, recruiting employees? Make sure you really do due diligence. The private practice study group just became a section of AAO, I would recommend networking there and learning from the more experienced.

 

[operaman]

I would vote for joining a group or taking an employed position for a couple years. Ideally you would find something nearby where you’d like to set up your own practice but far enough away that you won’t be bound by any non compete. It would give you a chance to learn and a chance to start building a reputation in the community before flying solo. There’s a huge learning curve on the business side of medicine.

It would be a lot easier to hang out your shingle if you already had a number of referring docs who liked you and would send you patients. If I went solo now, I’m sure I could have a steady stream of referrals on day 1 because I’m a known entity, but I don’t know how I would have done that a couple years ago when I was new. Thankfully, I had a built in stream of referrals plus a fellowship so all the local ENTs sent me complex cases right away.

Another consideration is the scope of your practice and how best to monetize that, plus just how entrepreneurial you are and whether your local market could support things like surgery centers and imaging that are often ancillary revenue streams for private practice docs. For me, my practice focus lends itself to an employed rvu bonus model quite well, but is too capital intensive to be as good in private practice at least in the beginning.

Remember there will be a long period where you can’t pay yourself a salary at all. Your overhead combined with slow insurance payments will see to that. The deck is increasingly stacked against the solo practitioner.

 

[TheLesPaul]

The solo practice is absolutely viable. There are a lot of us in surgical subspecialties to do it. You will take 3-6 months to break even. Take a lot of call. Also try to have some sort of cash-based service to offset insurance vagaries.