For Graduating Residents and Fellows: Employed or Private Practice Model?

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You are completing the formal training of your specialty and are now faced with how and where to practice medicine. Medical schools and residencies provide little information on the business of medicine. The Affordable Care Act is placing more constraints on how physicians practice their craft, and threats of lowered reimbursements from Medicare/Medicaid remain. Electronic medical records, malpractice insurance, health insurance, secretaries, billers and office managers must be addressed. What do you want your lifestyle to be like? What type of specialty did you choose? Where do you want to live?  All of these go into your decision-making process.

The numbers of solo primary care practitioners who provided care to a single set of patients have been steadily declining over the last decade while numbers of physicians working in employed, group situations has risen correspondingly. However, many physicians still choose private practice options, and employment isn’t necessarily for everyone. There are pluses and minuses to each situation, and graduating physicians should consider the positives and negatives in the light of their own personal situations and preferences.

In private small group practice, physicians are usually guaranteed a salary (income guarantee) for a few years in order to build up their own patient population. Afterwards, the physician’s income is based on their own revenue after paying overhead. In general, private practices are combining into larger groups, which can better negotiate with insurance companies as fee for service practices. In this situation overhead is shared with a greater number of doctors which can sometimes work to increase a hard working physician’s personal income. These groups allow physicians to practice as they see fit, with reimbursements based on performance and revenue brought in. Large private practice groups also may incorporate ancillary income, such as using their own free-standing day surgical centers, radiology services, and rehabilitation centers.

After the first few years, vacations and continuing medical education are paid out the physician’s own pocket, and when they are away, they are not generating income. Medical malpractice insurance (MMI) is often covered by the practice for the initial few years, but it is then up to you to cover payments. MMI yearly costs are based on your specialty, the area in which you practice, and claims made against you in the past. Rates have been on the increase over the past ten years. Private practitioners are able to choose which hospitals they work with, the equipment that they wish to use, and set their own schedules in terms of surgical days and numbers of patients seen per day. On average, they also earn significantly more income than their employed peers (see http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=11).

Employed physicians occur within various types of practices.  Private groups of 100 physicians or more are not unheard of.  These are run by a type of physician/administrator board in which those at the top make the decisions about how things are to be run, salaries, and which insurance companies to associate with, among others. In contrast, hospitals are now purchasing individual practices that are run by the hospitals with less physician autonomy than that of private practice. Other types of employed physician are academicians and hospitalists.  All of these have common as well as unique features.

More residents and fellows are trending toward a hospital employee model. It is seen as a way to assure a steady salary and an instant patient population. You do not have the luxury of choosing your partners, however. Lifestyle is also seen as improved, particularly for women who wish to have children and work based on family needs. Vacations are covered as well as continuing medical education requirements. Hours worked are more consistent. You may have better access to newer technology that private practices may not be able to afford. Some employees are allowed to negotiate their salaries based on performance and income brought into the practice. Others maintain a set salary or may experience a decrease, depending on practice parameters set in advance. Malpractice is covered by the hospital or group. You are unencumbered by overhead, or administrative issues/ burdens. The cost and implementation of electronic medical records is borne by the hospital.

Academic medicine offers the ability to teach students, residents and fellows, perform research, and see your own “private” patient base. Often your call will be much less frequent, and you have physicians in training to do some of the work that you would otherwise be obligated to do ( discharge summaries, day-to-day orders, following up on lab tests or radiologic studies, calling consults, etc…). You will stay on the cutting edge of medicine; however, salary tends to be lower in this model. Doctors accepted into academia are often the best in their field. Consultations with colleagues in your own or other departments are often only a few doors down from you. Academic medical centers often attract more difficult to treat patients, which is intellectually stimulating. Overhead, administrative issues, EMR implementation, malpractice premiums, and salary are all covered by the medical center.

Hospitalists are physicians who solely work in inpatient settings.  They are specialized in managing acutely ill patients. Some choose subspecialties such as critical care of post operative patients, including neurosurgery, cardiac surgery, transplants, and pulmonary medicine. Perinatologists work exclusively in the hospital setting as well. Upon discharge, these patients return to their primary physician of record.

Despite the career path you initially choose, you are not bound to that practice type. Using a legal expert to evaluate your contract, including an acceptable exit clause, will assure that you will be able to change practice types within your own geographic area. Due diligence with research, speaking to recent graduates who entered different types of practices, and consulting with attendings will allow you to determine the best practice model for you.

Browse Private Practice & Employed Physician Jobs at HospitalRecruiting.com: https://www.hospitalrecruiting.com/jobs/Physician-Jobs/.