Where to practice?

A look at the most common models that physicians encounter in the job search.

By Debbie Swanson | Feature Articles | Spring 2020

 

“There is no one-size-fits-all job coming out of residency,” says Carlene MacMillan, M.D. “Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.” - Photo by Jakub Redziniak

“There is no one-size-fits-all job coming out of residency,” says Carlene MacMillan, M.D. “Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.” – Photo by Jakub Redziniak

During the job search, there’s plenty to focus on: growth opportunities, patient profiles, salary, benefits and geographic location, to name a few. But before you think about any of those details, you need to figure out what employment model best suits you. From a Level I trauma center to a small specialized practice to a varied group practice, there are many settings in which to practice medicine. Each comes with its pros and cons.

Considering your ideal employer will make your search more efficient. You can weed out places that aren’t a good fit and focus on the ones that are. That means you’ll be more likely to end up in a job you love and avoid having to do the search all over again in a few years. This summary of the popular employment models will help you get started.

Hanging up your shingle: private practice

Striking out on your own is a time-honored vision of being a doctor. Though its popularity has declined in the past few decades, going solo can still be attractive. In a 2018 survey, the Physicians Foundation reported that the number of physicians in solo practice had risen just slightly from 2016 to 2018, but the overall number was still smaller than it was in 2012.

The advantages of going solo are many. Without partners or a management team, you have autonomy over how you run your practice. You also have the flexibility of setting your own schedule, which can be appealing if you have a young family or another enterprise on the side. There’s also more flexibility over income. After covering overhead and expenses, the remaining revenue is yours to use as you see fit.

Many solo practitioners enjoy getting to wear many hats. In addition to clinical practice, you’re the decision-maker for all aspects of running the business—from budgeting and choosing equipment and supplies to training new employees and marketing. How you split your time is up to you, and you can hire staff to oversee the segments of business that aren’t your strong suit.

“Private practice, as I presently maintain, is often more financially rewarding. It affords the freedom to set [your own] schedule but often comes with additional stresses of becoming a small business owner,” says Michael Sinel, M.D., who now runs a solo practice after having worked in both a hospital and a multispecialty clinic.

Going solo certainly has its disadvantages. Your practice may not be as appealing to insurance carriers, who set their sights on bigger fish. You won’t have the advantage of strolling down the hall to collaborate with a colleague. And when it comes to divvying up call hours or planning time off, no alternate physicians are readily available. Balance can also be an issue. Because the solo physician juggles so many responsibilities, carving out consistent non-working hours can be a challenge.

Excitement and variety: hospital employment

Hospitals are a popular choice among physicians, and that popularity is rising. As of early 2018, the number of physicians employed by hospitals had grown by 70 percent since mid-2012, according to a study released by Avalere Health and the Physicians Advocacy Institute. This is due in part to the rapid rate at which hospitals are acquiring medical practices. In the same timeframe, the number of physician practices acquired by hospitals grew from 35,700 to more than 80,000.

Regardless of how physicians end up there, hospital systems offer many advantages. Chief among these: variety. Hospitals typically offer a more diverse set of patient cases, and hospitals also vary widely from one another. Factors such as overall popularity, patient demographics, typical caseloads, specialties and more will affect your day-to-day experience. The managing entity also influences the hospital environment. A hospital may be privately owned, government-run, religiously or academically affiliated, or run by physicians. Each of these systems will affect the hospital differently.

Another bonus is the availability of resources. Large or small, most hospitals have a wide array of medical personnel, labs and equipment. For a newer physician, this presents many learning opportunities. And since other employees are responsible for things like paperwork, routine care and non-clinical tasks, physicians can focus more on patient care.

“I found the collegiality and opportunities to learn through the extensive experience of my senior colleagues to be invaluable,” says Sinel. He was a full-time hospital employee at Cedars-Sinai Medical Center in Los Angeles early in his career. He says, “The collegiality, clinical conferences and easy access to multiple specialists were critical in developing well-rounded medical competence and confidence.”

After becoming an associate clinical professor at the UCLA School of Medicine, Sinel began complementing his clinical work with teaching. “I greatly enjoy the combined intellectual stimulation and clinical challenges,” he says.

Hospital work does have some downsides. Although many employers these days emphasize work/life balance, hospital physicians still tend to work long shifts and non-traditional hours. Patient arrivals can be unpredictable, which means shifts don’t always end when they’re supposed to. And depending on hospital location, a physician may frequently witness issues stemming from gun violence, drug addiction or homelessness. It can be wearying to treat these issues over and over again.

Joining the team: group practices

The group practice model traces its roots to the late 1800s when the Mayo Clinic in Rochester, Minnesota, widely regarded as a the first group practice, opened its doors. By 1929, the Mayo Clinic was world-renowned and employed 386 physicians and dentists. Today, group practices are common, and they vary greatly in size and number of specialties.

One major appeal of the group practice model is that it means having colleagues. From collaboration and learning to coverage for call and holidays, there are benefits to being part of a group. Groups also usually have administrative and support personnel who free physicians from business-related tasks. And group practices offer a fairly predictable patient flow, enabling physicians to maintain routine shifts with minimal holiday, weekend or late-night work.

However, if you’re considering a job at a group practice of any kind, you should be aware of the growing trend toward hospital acquisitions. From 2012 to 2018, hospital acquisitions of group practices have increased by 128 percent. Before accepting any group practice job, you should understand how likely that is and how it might affect your employment, so don’t hesitate to ask about it during an interview.

A unified focus: single-specialty group practice

Single-specialty group practices are exactly what they sound like: organizations that employ several physicians in the same specialty, such as orthopedics or OB/GYN. These groups tend to be smaller, but the model is popular. In a 2012 survey by the American Medical Association, 45.5 percent of physicians called single-specialty practices the most common arrangement.

For a new physician, working with established colleagues in your specialty presents a valuable learning opportunity. Many single-specialty groups are run by physicians, meaning you may have a say in decision-making and practice direction. But it’s not unusual to have a management team, particularly in larger groups.

Some practice groups evolve from a solo practice, as was the case with Brooklyn Minds Psychiatry, a mental health group practice in New York cofounded by CEO Carlene MacMillan, M.D. “It has been quite a journey from being a sole proprietor working in solo practice several years ago to being CEO of a growing psychiatric practice,” she says. “[We] now have 14 clinicians and a staff of approximately 40 people.”

One downside of a single-specialty group is the lack of referrals. When a group only offers one specialty, patients have to go outside the group for additional types of care, and there aren’t referrals coming from other specialties within the practice. Another downside is that patient distribution may not favor newcomers to the practice. If you’re exploring a specialty group practice, be sure to ask how patients are distributed and whether you’ll be responsible for establishing your own patient panel.

Combined expertise: multispecialty group practices

"When I started my career, a group practice made a lot of sense, as there was a steady referral base," says York Yates, M.D. - Photo by Austen Diamond

“When I started my career, a group practice made a lot of sense, as there was a steady referral base,” says York Yates, M.D. – Photo by Austen Diamond

Multispecialty group practices employ physicians in different areas of medicine. These groups are typically larger than single-specialty groups; some even employ thousands of physicians. Unlike single-specialty groups, multispecialty groups have the upside of internal referrals. Patients are likely to stay within the group when they need additional care from a different physician.

York Yates, M.D., has been in plastic surgery at the Tanner Clinic, a multispecialty group in Layton, Utah, for 16 years. “When I started my career, a group practice made a lot of sense, as there was a steady referral base,” he says. “Referrals build the practice, and it’s nice to have physicians you respect to whom to refer. There is also a nice sense of camaraderie and community in a multispecialty group.”

The downsides of multispecialty groups often center around group dynamics. Some physicians or specialties may feel that they are more valuable than others or that they attract more patients and deserve more dividends. Management style can be an issue. Many larger mixed-specialty groups are run by a management team, and leaders may or may not come from a medical background. Most larger groups operate with established practices and protocols, which can also create conflict. “[A physician may] find that decisions in the group’s best interest may be at odds with their own,” adds Yates. “Those who have a tough time compromising [may] struggle in a group practice setting.”

Yates has observed his practice grow and change over time. This is common as groups evolve and expand their offerings. “As my practice has matured, we have stopped offering insurance cases, and the environment I practice in runs more like a solo practice within the multispecialty clinic. I have a separate EMR, separate billing, separate branding and separate advertising,” he says.

Embracing opportunity: locum tenens

A newer model of employment, locum tenens arrangements began in the 1970s and quickly caught the attention of both physicians and employers. A locum tenens physician is a licensed, qualified physician who takes short-term assignments, as brief as a few days or as long as a year. These assignments fill in when a physician becomes temporarily unavailable or an employer experiences a temporary caseload increase. Locum opportunities are available all over the country and are typically found through a staffing agency.

Many physicians are attracted to this model due to its flexibility and variety. It offers the chance to explore different practice settings and geographic locations while meeting and working with new colleagues. However, downsides include a lack of job permanence and financial stability as well as the emotional strain of changing your work environment frequently.

Miechia A. Esco, M.D., a vascular surgeon, has been a locum tenens physician for five years through LocumTenens.com. Having previously worked in many other practice models, she appreciates the flexibility of locum work and its work/life balance benefits.

“I work as much or little as I desire and in locations that I choose. [This] gives me the freedom to travel, enjoy hobbies and spend time with family and friends,” she says. “For instance, I took a month off to climb Mount Kilimanjaro and explore the region. There was no pressure to ask for time off, worry about vacation days or to find coverage.”

Satisfaction and benefits: working for the government

Almost every sector of government needs physicians. Aside from the typical government-run hospitals and clinics, physicians also work for government bureaus, correctional institutions, research labs and more. These roles range from serving as a private physician to an individual or a group to conducting medical research and serving as a physician in a hospital or clinic.

Many of these opportunities allow you to put a different spin on the traditional clinical practice of medicine. For example, a recent job listing for the CIA describes the role as follows: “Utilizing your clinical expertise in a medical consultation model, you will help advance the CIA mission where it intersects with medical issues.” Other bureaus, such as the FBI and CDC, offer similar opportunities.

VA hospitals and clinics are another type of government employer. VA health care facilities are widespread, serving more than nine million enrolled veterans and their families each year, and these institutions are held in high regard. In 2017, the Department of Veterans Affairs was ranked #17 by Reuters in their list of the World’s Most Innovative Research Institutions. Many physicians find the work rewarding as it offers a chance to help veterans and their families.

Regardless of your place of employment, government benefits can offer significant savings. For example, under the Federal Tort Claims Act, federally-employed physicians have certain financial protection against common malpractice lawsuits. And the Public Service Loan Forgiveness program allows some government-employed physicians to erase their student loan balances after meeting certain stipulations. If government work appeals to you, it’s worth researching the specific details of these policies to see how they might benefit you.

So how to choose?

Finding the right employer can be an overwhelming experience, and for physicians, there are extra criteria to take into account. Before weighing your options, take a step back and consider the following questions:

  • Do you prefer to spend your time mainly on clinical work, or do you enjoy wearing a variety of hats?
  • Do you enjoy collaborating with others, or do you prefer to solve problems through solitary research and study?
  • Do you prefer being surrounded by people practicing a variety of specialties or diving deep into your specialty?
  • What other commitments or restrictions are on your plate?
  • Consider your personality and lifestyle. Do you prefer a set schedule, or can you handle long and/or unpredictable hours?
  • What type of management do you prefer: physician-led or non-physician-led?
  • Do you like to network and market yourself?
  • Do you like variety or predictability in your workday?
  • Do you thrive in a fast-paced, fluid environment, or do you like organization and structure?

Remember that what’s right for someone else isn’t necessarily right for you, and that what appealed to you a few years ago may no longer be what suits you now. And though you want to make a wise decision, remember you can always change course if you take a wrong turn.

“There is no one-size-fits-all job coming out of residency,” MacMillan says. “Very few doctors keep the first job they took. I certainly did not, but I’m grateful for the job that I had. Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.”

 

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