CTU Surgeon

5+ Year Member
Jul 12, 2014
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Junior resident here, probably a little early for such a question, but I’m very curious. What are the major cons of private practice that we might not foresee or be aware of while we are housed within academia for most of training?

i always figured I’d be an academic, but the farther I get I to residency, the more I wanna be a generalist. With that, I’ve started romanticizing the idea of what life in PP must be like. I’m looking to hear some stories to help me have a balanced understanding of the less beautiful aspects of it. Obviously there are still options outside of academia that can be very different—employed by a system vs partner in a larger group vs single partner or small practic, etc.—but I would love to have some more perspective if anyone has a moment to share about what they didn’t expect that irks them.
 

OtoHNS

ENT Attending
Aug 16, 2010
450
183
Status
  1. Attending Physician
I am in solo practice in a large metro area.

Pros:
1. No one tells me what to do
2. I have complete control of my workflow and lifestyle.
3. All of my patients are MY patients- no cross-covering or sharing with other docs. I've been able to develop great multi-year professional relationships with many patients and families over the years.
4. I get 100% of the financial profits from my work

Cons:
1. It can feel lonely compared to residency or working in a large group.
2. There is perpetual stress over getting new patients in the door and keeping cash flowing. Usually this is pretty low-level stress, but the recent pandemic has not been helpful for the bottom line. Even in normal times, it takes constant attention to some extent.
3. No one is going to buy me fancy HD monitors and other brand new equipment. Fortunately, the used stuff works fine.
4. There is no one to share call with. I choose not to take any ER or hospital call, but I am on call 24/7/365 for my own patients. I do limit calls between 10p-8a for fresh post-op patients only. My patients are quite considerate, so I do not get many after-hours calls, but your mileage may vary on this depending on where you practice.
5. If I go on vacation or am out sick, my business has zero income.

Could be a pro or a con:
I have 100% of the responsibility for managing the business, marketing, and HR side of the practice. Even if you hire an office manager, billing person, or marketing services, you need to stay aware of what is going on. I know another local ENT who had >$100k embezzled by their office manager because they weren't paying attention to the books.

Overall, I am very happy in my situation and would choose it again.
 

turboE36

5+ Year Member
Sep 18, 2014
29
7
I am in solo practice in a large metro area.

Pros:
1. No one tells me what to do
2. I have complete control of my workflow and lifestyle.
3. All of my patients are MY patients- no cross-covering or sharing with other docs. I've been able to develop great multi-year professional relationships with many patients and families over the years.
4. I get 100% of the financial profits from my work

Cons:
1. It can feel lonely compared to residency or working in a large group.
2. There is perpetual stress over getting new patients in the door and keeping cash flowing. Usually this is pretty low-level stress, but the recent pandemic has not been helpful for the bottom line. Even in normal times, it takes constant attention to some extent.
3. No one is going to buy me fancy HD monitors and other brand new equipment. Fortunately, the used stuff works fine.
4. There is no one to share call with. I choose not to take any ER or hospital call, but I am on call 24/7/365 for my own patients. I do limit calls between 10p-8a for fresh post-op patients only. My patients are quite considerate, so I do not get many after-hours calls, but your mileage may vary on this depending on where you practice.
5. If I go on vacation or am out sick, my business has zero income.

Could be a pro or a con:
I have 100% of the responsibility for managing the business, marketing, and HR side of the practice. Even if you hire an office manager, billing person, or marketing services, you need to stay aware of what is going on. I know another local ENT who had >$100k embezzled by their office manager because they weren't paying attention to the books.

Overall, I am very happy in my situation and would choose it again.

How do you compete with academic institutions or large groups in your area? Is it mostly excellent marketing strategy or do you offer something others do not (both from a business perspective and clinical)? Are you doing any larger oncologic cases?
 
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OtoHNS

ENT Attending
Aug 16, 2010
450
183
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  1. Attending Physician
How do you compete with academic institutions or large groups in your area? Is it mostly excellent marketing strategy or do you offer something others do not (both from a business perspective and clinical)? Are you doing any larger oncologic cases?

It's a number of things.

-There are still some independent PCP practices in my area and they refer some patients. Many solo and small practice PCPs like to refer to small practice specialists.
-I've got a good web design/SEO guy and get a lot of patients from Google search
-I've got some good marketing and referral systems in place. For this stuff, I would read Dan Kennedy's book "No B.S. Direct Marketing"- that will take you down a rabbit hole. Most of what I do is consistent with the principles in that book. I would NOT recommend trying to D.I.Y. your marketing- find real experts and pay them to do it for you. You need to understand the principles to figure out who is for real and who is just going to take you to the cleaners (95%+ of "marketing" agencies).
-Many patients like going to a smaller practice- they get more personalized care, they talk to a person (usually the same person) every time they call, etc.

I don't do any big head and neck cases. Honestly, it's pretty rare that I even see a H+N cancer, and most of the time, they are more amenable to chemo/rads than surgery. In the event that someone needs a big whack, I can send them to the Ivory tower.
 
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Dec 3, 2016
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It's a number of things.

-There are still some independent PCP practices in my area and they refer some patients. Many solo and small practice PCPs like to refer to small practice specialists.
-I've got a good web design/SEO guy and get a lot of patients from Google search
-I've got some good marketing and referral systems in place. For this stuff, I would read Dan Kennedy's book "No B.S. Direct Marketing"- that will take you down a rabbit hole. Most of what I do is consistent with the principles in that book. I would NOT recommend trying to D.I.Y. your marketing- find real experts and pay them to do it for you. You need to understand the principles to figure out who is for real and who is just going to take you to the cleaners (95%+ of "marketing" agencies).
-Many patients like going to a smaller practice- they get more personalized care, they talk to a person (usually the same person) every time they call, etc.

I don't do any big head and neck cases. Honestly, it's pretty rare that I even see a H+N cancer, and most of the time, they are more amenable to chemo/rads than surgery. In the event that someone needs a big whack, I can send them to the Ivory tower.
thank you for this, how is the plastics exposure? can you do a lot if you wanted ?
 

OtoHNS

ENT Attending
Aug 16, 2010
450
183
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  1. Attending Physician
thank you for this, how is the plastics exposure? can you do a lot if you wanted ?

The demographics of my area are not conducive to a cosmetic practice. There are plenty of cosmetic docs in the fancier parts of the metro area (30 minutes from my practice). I don't want to do that stuff anyway.

One of my ENT competitors did a facial plastics fellowship but as far as I can tell, he just does general ENT now.

There is a plastic surgeon employed by the hospital near me, but it seems like he just does reconstructive and trauma cases.

If you want, you could probably do trauma or reconstructive cases anywhere. For cosmetics, you need to plan carefully where geographically to set up your practice and learn how to market yourself effectively.
 
Dec 21, 2007
1,922
2,294
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  1. Attending Physician
Junior resident here, probably a little early for such a question, but I’m very curious. What are the major cons of private practice that we might not foresee or be aware of while we are housed within academia for most of training?

i always figured I’d be an academic, but the farther I get I to residency, the more I wanna be a generalist. With that, I’ve started romanticizing the idea of what life in PP must be like. I’m looking to hear some stories to help me have a balanced understanding of the less beautiful aspects of it. Obviously there are still options outside of academia that can be very different—employed by a system vs partner in a larger group vs single partner or small practic, etc.—but I would love to have some more perspective if anyone has a moment to share about what they didn’t expect that irks them.

Having just gone through the job search, the major cons of PP to me were:

1. Buy-in (assuming you're not going to go strike out on your own off the bat which few people do out of training) - often unfair from my point of view buying into the practice. A couple were reasonable in terms of time and money but some were 5+ years and 200K+ which to me is outlandish. You're buying into equipment and property and ancillaries etc etc which sometimes is already devalued. Which leads into the next:

2. Equipment. In PP you usually have to pay for the equipment out of your pocket. So the medtronic stealth system you've grown to love? Hundreds of thousands of dollars. The pretty 4K screens? The specialized instruments? Harmonic? Strobe? Microlaryngeal instrumentation? That **** is all expensive, and the established partners have been "doing it just fine for the last 20 years" looking through the eyepiece or using their 40 year old microscope so good luck convincing them it's necessary.

3. Navigating insurance / the business side of things. Self explanatory but I think underestimated even for those of us who know it'll be a pain in the butt. This was what ultimately deterred me from private practice out the gate. I dont understand this enough to look at a practice's books and practices to say, "hey this isn't optimal" or know what's going to tank the practice down the road. Better to educate myself and tackle this down the road.

4. Stability - the less you work the less money you make, generally speaking. When COVID hits again (or just continues unabated as is) and you cant do elective surgeries or patients aren't coming in, but you still have overhead to pay what are you going to do? In an employed setting the hospital system provides a buffer and stable salary.

5. Academic inquiry/growth. To be honest from what I've seen the vast majority of PP guys become stale and risk adverse. Im still not sure if that's a good or bad thing. But unless you're in a large group it doesn't seem like you're going to have rounds and bouncing ideas off each other to the same extent as in training. Research is more difficult. You're unlikely to do significant teaching/training (there are exceptions to this).

Obviously Im not deep into practice at all but figured the POV from a recent grad might help. I dont really know much about the plastics scene except that its very variable depending on how many plastics guys are around. Generally speaking everyone likes mohs recon and it's kind of tough to get into. Cosmetics is just market dependent.
 
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OtoHNS

ENT Attending
Aug 16, 2010
450
183
Status
  1. Attending Physician
Having just gone through the job search, the major cons of PP to me were:

1. Buy-in (assuming you're not going to go strike out on your own off the bat which few people do out of training) - often unfair from my point of view buying into the practice. A couple were reasonable in terms of time and money but some were 5+ years and 200K+ which to me is outlandish. You're buying into equipment and property and ancillaries etc etc which sometimes is already devalued. Which leads into the next:

2. Equipment. In PP you usually have to pay for the equipment out of your pocket. So the medtronic stealth system you've grown to love? Hundreds of thousands of dollars. The pretty 4K screens? The specialized instruments? Harmonic? Strobe? Microlaryngeal instrumentation? That **** is all expensive, and the established partners have been "doing it just fine for the last 20 years" looking through the eyepiece or using their 40 year old microscope so good luck convincing them it's necessary.

3. Navigating insurance / the business side of things. Self explanatory but I think underestimated even for those of us who know it'll be a pain in the butt. This was what ultimately deterred me from private practice out the gate. I dont understand this enough to look at a practice's books and practices to say, "hey this isn't optimal" or know what's going to tank the practice down the road. Better to educate myself and tackle this down the road.

4. Stability - the less you work the less money you make, generally speaking. When COVID hits again (or just continues unabated as is) and you cant do elective surgeries or patients aren't coming in, but you still have overhead to pay what are you going to do? In an employed setting the hospital system provides a buffer and stable salary.

5. Academic inquiry/growth. To be honest from what I've seen the vast majority of PP guys become stale and risk adverse. Im still not sure if that's a good or bad thing. But unless you're in a large group it doesn't seem like you're going to have rounds and bouncing ideas off each other to the same extent as in training. Research is more difficult. You're unlikely to do significant teaching/training (there are exceptions to this).

Obviously Im not deep into practice at all but figured the POV from a recent grad might help. I dont really know much about the plastics scene except that its very variable depending on how many plastics guys are around. Generally speaking everyone likes mohs recon and it's kind of tough to get into. Cosmetics is just market dependent.

I think most of your comments are fair. A few thoughts:

1. re. Buy-ins. I would agree they are usually higher than they need to be. They are negotiable, as is the employment term before becoming partner. A high buy-in might be worth it in the right situation, too. And just because you are hired by a practice, you are obviously not obligated to buy in as a partner. Before getting hired by any job, you should have an exit plan in place just in case. It is probably advisable to consult with a contract attorney about this stuff.

2. re. Equipment. Definitely true, though many of your examples are usually purchased by the hospital or surgery center. If you bring them a lot of cases, they are a lot more willing to buy expensive equipment. For expensive office equipment, you can finance the purchase if it's something you really want/need.

3. Agree completely.

4. Agree. Though hospitals are hurting too, and no job is 100% safe. The PPP loan program kept my practice stable during April/May, and the AAO was very helpful in keeping our community advised on how to get this funding.

5. Agree. The AAO has some good online resources where you can ask questions, but it is certainly not the same as being in academia or a large practice.
 
Mar 24, 2018
30
36
Status
  1. Attending Physician
Pros
1. Complete control over my schedule and life. I've established a mostly outpatient practice. My work revolves around my life, not the other way around.
2. No administrator breathing down my neck on any part of how I practice medicine.
3. Having the hospital and ASC cater to MY needs, not the other way around.
4. Not having to deal with residents/medical students. I do the whole operation, I run my clinic efficiently. I don't miss rounding/teaching/academic BS at all.
5. For the most part super satisfied patients.
6. Very financially rewarding, even in this modern day medicine of cost-cutting and decreasing reimbursement.

Cons
1. Overhead, overhead, overhead.
2. Anxiety over whether or not referring docs love me or hate me given the time of year (albeit this is mostly just my own neuroticism)
3. Can be lonely at times.
4. Unless you have a specific interest, big whacks or super complex stuff gets referred out.

As an aside, even larger buy-ins (200k) sound like a big number coming out of residency/fellowship but it really isn't that bad. Of course, do your due diligence and see what the buy-in gets you (ASC schares, audio/allergy, building investments, lab/CT scan, etc.) but for the most part the money comes back to you many times over if things are on the up and up.
 
Dec 21, 2007
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I think most of your comments are fair. A few thoughts:

1. re. Buy-ins. I would agree they are usually higher than they need to be. They are negotiable, as is the employment term before becoming partner. A high buy-in might be worth it in the right situation, too. And just because you are hired by a practice, you are obviously not obligated to buy in as a partner. Before getting hired by any job, you should have an exit plan in place just in case. It is probably advisable to consult with a contract attorney about this stuff.

2. re. Equipment. Definitely true, though many of your examples are usually purchased by the hospital or surgery center. If you bring them a lot of cases, they are a lot more willing to buy expensive equipment. For expensive office equipment, you can finance the purchase if it's something you really want/need.

3. Agree completely.

4. Agree. Though hospitals are hurting too, and no job is 100% safe. The PPP loan program kept my practice stable during April/May, and the AAO was very helpful in keeping our community advised on how to get this funding.

5. Agree. The AAO has some good online resources where you can ask questions, but it is certainly not the same as being in academia or a large practice.

I think the part about getting a contract attorney cant be overstated. Even one of the cookie cutter ones online (AAO was advertising one recently) that just gives you MGMA data for your region and goes over your contract. I felt this was well worth the money and helpful in negotiating my salary and starting to understand contracts.

Re: equipment. I interviewed at several hospitals and in a non-employed model I almost always got the "we'll take a look at needs" or "we can send it through capital after you start" when I asked about equipment. Capital takes like a year. For me that was a big red flag if they weren't willing to buy equipment up front and expected me to use the old sets starting out until I demonstrated case loads.
 
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Dec 21, 2007
1,922
2,294
Status
  1. Attending Physician
Pros
1. Complete control over my schedule and life. I've established a mostly outpatient practice. My work revolves around my life, not the other way around.
2. No administrator breathing down my neck on any part of how I practice medicine.
3. Having the hospital and ASC cater to MY needs, not the other way around.
4. Not having to deal with residents/medical students. I do the whole operation, I run my clinic efficiently. I don't miss rounding/teaching/academic BS at all.
5. For the most part super satisfied patients.
6. Very financially rewarding, even in this modern day medicine of cost-cutting and decreasing reimbursement.

Cons
1. Overhead, overhead, overhead.
2. Anxiety over whether or not referring docs love me or hate me given the time of year (albeit this is mostly just my own neuroticism)
3. Can be lonely at times.
4. Unless you have a specific interest, big whacks or super complex stuff gets referred out.

As an aside, even larger buy-ins (200k) sound like a big number coming out of residency/fellowship but it really isn't that bad. Of course, do your due diligence and see what the buy-in gets you (ASC schares, audio/allergy, building investments, lab/CT scan, etc.) but for the most part the money comes back to you many times over if things are on the up and up.

The referring docs stuff I think is also a huge aspect of private practice and could be considered a con. If you're a charmeleon and great at networking and willing to give talks and reach out and etc etc it can be great. I personally am not and don't have much patience for community talks. I'm in a small group practice, hospital employed and the nice thing is that the docs have nowhere else to send patients. Not that I'm a dick to referring doctors or anything, but it's nice to not have to worry about that starting out.
 

Pir8DeacDoc

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Mar 27, 2004
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A lot of good thoughts on this thread. Some I think are over generalizations. But fair points none-the-less.

I have been in PP for my entire eight years out of training. However, I've been in a few different practices because the dynamics in PP can be interesting. Making money and personality mesh, especially in small practices, can sometimes be difficult.

I have settled in well currently and find a lot of elements that I Love!
- I do what I want to do. No hospital admin has any power over me. Beyond my hospital call duties as part of my privileges, I am my own man. And ultimately they aren't going to rock my boat. I make them a lot of money and they don't pay me a dime. I don't go to meetings that I don't want to attend.
- I work as little or much as I want. Vacation/CME/kids event is my call. yeah, it may hurt me a little financially, but I don't have to OK anything with anyone. If I want to finish clinic early, then I finish clinic early. Despite that, the financials have been well above what I was seeing for employed positions. See below
- I get a nice cut of ancillary revenue. This includes hearing aids, allergy shots, PA revenue, etc. This passive income stream is sizable at my practice.
- I have the option of ownership in an entirely physician owned ASC. This is another passive income stream that is sizable. This lets me make money while I am on vacation.
- I can do whatever mix of cases I want to do. I don't particularly enjoy complex ear cases or cosmetics. My partner likes cosmetics. So I send them along to him. And the ivory towers are always happy to tackle complex ears.

Cons:
- There is a constant need to watch overhead/expenses. I monitor monthly reports and am keenly aware of the financials at any given time.
" - I interact with fewer other otos and do "smaller" cases. Though I still do thyroids/parotids, etc. Just not huge cancer wacks.
- no guaranteed money. I make what I generate. But the ancillaries really have seemed to buffer when my clinical months have been slower.
- buy ins. These can be big, but can be done as deferred compensation and can have good long term upside.


Overall, I love the autonomy of doing what I want on my own terms. With the added income stream of ancillary services, I have been very pleased with my overall compensation.
 
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Pikevillemedstudent

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Great discussion here. And I agree with most everything being said. Ive worked in a PP and hospital employed. For me, the employed setting has been far and away better. I will provide some insight since few have from that perspective. But I will say that I'm likely the exception and not the rule.

I work in an underserved area with a large amount of medicaid. Private practice here was frustrating, busy, and not as financially rewarding. We sold our practice and joined the local hospital and moved into their clinic building. Immediate upgrade in equipment, number of staff, and salary. Because its underserved and difficult to recruit another ENT to the area, I command a salary that is equal to the offers I received in metro PP settings as a partner. I'm the head of the department. Q3 call. No facial trauma. No admin breathing down my neck and get 7 weeks PAID vacation per year. I see between 100-120 patients per week in the office and operate 2 days per week, about 20 cases total. No concerns about lay off or furlough with the pandemic with the hospital buffer. I work hard, never say no to seeing a patient, and always ensure that no one out works me in the department. However, I work less than 40 hours per week. I'm extremely happy but most would probably not want to live in the area that I live. And the hands off approach from hospital admin is probably unique to the area and a product of my department always exceeding expectations.
 
Dec 21, 2007
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  1. Attending Physician
Great discussion here. And I agree with most everything being said. Ive worked in a PP and hospital employed. For me, the employed setting has been far and away better. I will provide some insight since few have from that perspective. But I will say that I'm likely the exception and not the rule.

I work in an underserved area with a large amount of medicaid. Private practice here was frustrating, busy, and not as financially rewarding. We sold our practice and joined the local hospital and moved into their clinic building. Immediate upgrade in equipment, number of staff, and salary. Because its underserved and difficult to recruit another ENT to the area, I command a salary that is equal to the offers I received in metro PP settings as a partner. I'm the head of the department. Q3 call. No facial trauma. No admin breathing down my neck and get 7 weeks PAID vacation per year. I see between 100-120 patients per week in the office and operate 2 days per week, about 20 cases total. No concerns about lay off or furlough with the pandemic with the hospital buffer. I work hard, never say no to seeing a patient, and always ensure that no one out works me in the department. However, I work less than 40 hours per week. I'm extremely happy but most would probably not want to live in the area that I live. And the hands off approach from hospital admin is probably unique to the area and a product of my department always exceeding expectations.

Any particular secret to seeing 40 patients a day?
 
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