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(03-10-2022, 06:47 PM)Guest Wrote: (03-10-2022, 05:00 PM)socrates Wrote: I am in solo private practice. Can try to answer questions anyone might have. There are obviously trade offs.
What is a day in the life like ? How many surgeries would you say you perform annually ? What are theses "trade offs" you mention ? What region of the country is this ? How much do you make ? Are you planning on buying a second yatch ?
and most importantly, what made you choose an independent-style PP over joining a group or academics ?
Depends on the day. For OR days, I roll in ~7:20 to sign my first start in. Make rounds while anesthesia is delaying. Clinic days I take my kid to school before heading in to the office.
Trade offs are that I spend more time on administrative tasks like managing a practice. I have to find good staff, pay them well enough they won't leave, and deal with many things an employed practice that I would not. I have far more autonomy and discretion over my day-to-day schedule and am accountable only to myself. I need a day off, I take it. I want to travel for a conference or vacation, no problem. Arranging coverage can prove problematic. I eat what I kill. Private practice is not particularly forgiving, so many of the more interesting or risky cases get passed on to the major medical center as a result.
As someone else mentioned, I do have leverage to get what I want. I do 300+ cases a year and my practice is entirely elective, entirely insured. I do a mix of ~60-70% spine and 30-40% cranial. I am in the southeast. I make well more than what my colleagues who are employed make. With the Ukraine thing, yachts are cheap now, so I'm actually on my 3rd.
For me, it came down to autonomy. Academics eats 50% of your income right off the bat. Your first years in practice, you are basically super-chief. Taking call and garbage cases that the guys higher on the totem pole gift you (e.g. wound washouts, epidural abscesses, or microdiscs in the BMI 60 pts). Certainly you do get some cases in your sub-specialty, and if that's spine it tends to be more common early on. Likewise, if there is someone established in your specialty, and you are adding depth, it can be frustrating. I entertained joining a group, and do get offers from time-to-time of groups in my area to join them. Ultimately, I think it was a similar thought process that I wanted control over my own destiny and not be beholden to an administrator or senior partner who would tell me what cases I could or couldn't do, or how the group would spend resources for things like networking or marketing.
It is not an easy path to take, but it is possible. The comment about EMR does not seem to be true, there are many companies that handle this side of the practice. The larger barrier to entry is financially e.g. having to pay overhead costs while there aren't enough patients to cover expenses. Hospitals increasingly want to employ the surgeons and will require a coverage agreement with another surgeon or group which can be prohibitively difficult to obtain. Insurance payers have a boilerplate for any new applicants indicating their panel is closed and to re-apply again in 6 to 12-months. When you do become par for their plan, they refuse your medical decision making for prior authorization of a case, and then refuse to pay because there is an issue with the coding. It can be rather defeating.
In any case, after a while things start to run smoothly and the revenue comes rolling in. I would be happy to help anyone who is interested in starting their own practice. Perhaps it is a vestige of the past, but I did not go in to medicine to answer to an administrator.
Hi Socrates, thank you for your insightful post. I have a few questions that I hope you could answer. Do you hire any midlevels (PAs/NPs) in order to provide coverage, surgical first assist, and/or take call on the night shift so you can sleep and attend to the patient in the morning? Or is this even necessary? What exactly is the best division of labor for a solo practice? How can a midlevel(s) help you with a solo practice?
I have heard the opposite with regards to solo practice, i.e. you get overworked with constant call, and as a result you work long hours with little opportunity for a vacation. How accurate is this?
How complicated are the financial barriers and start up costs with regards to opening a solo practice? Would it be helpful to be a hospital-employed neurosurgeon/academic hospital for the first 2-3 years of your career and then invest those earnings into a solo practice?
Finally, what are the barriers with regards to visa/permanent residency a surgeon coming from a jurisdiction such as Canada would face with regards to opening a solo practice in the USA? How can they be best overcome?
Thanks again.
Bump.
Anyone have some insight into common pitfalls regarding joining an independent practice? Interviewing for jobs currently and interested to see what things are common traps to avoid. Looking at larger independent groups.
Socrates.
I’ve been told you can go into independent practice but then its hard to jump back into academics.
Can you comment on going into academics and the possibility of breaking off and going independent in 5 or so years if that’s what you might want at that time?
Do you think hospital-employed positions will ever match private practice income potentials? That is, do you foresee hospital-employed contracts offering 1 million income potentials?
Doubt they’ll ever match it because hospital admins will always take some off the top. Thing with private practice is it’s probably harder to initially get that high six figure/seven figure income since you have to build your referral base (or if in multi provider group you have to cut your teeth as junior partner to earn the right to enjoy the profit sharing) whereas hospital employed already has referrals somewhat setup and has the financial coffers to support your higher salary as you start up your practice. But you’ll likely top out quickly in hospital practice since you’re dependent upon them (and some may require you sign a noncompete, though I feel like that’s more common with PP groups). But in private practice once you’ve built the referrals network, your income is directly related to how busy you are. Joining one or a few other surgeons in a group can help defray initial start up costs (hiring nurse, office coordinator, obtaining privileges at local hospital or ASc). Hospital employed also has benefit of hospital being the one who deals with insurance (or they at least should take care of that) and they should cover your malpractice.
I would argue hospital-employed is better than private practice because you can essentially guarantee 800k income without having to work extra hard.
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(08-15-2022, 07:21 PM)Guest Wrote: Hi Socrates, thank you for your insightful post. I have a few questions that I hope you could answer. Do you hire any midlevels (PAs/NPs) in order to provide coverage, surgical first assist, and/or take call on the night shift so you can sleep and attend to the patient in the morning? Or is this even necessary? What exactly is the best division of labor for a solo practice? How can a midlevel(s) help you with a solo practice?
I have heard the opposite with regards to solo practice, i.e. you get overworked with constant call, and as a result you work long hours with little opportunity for a vacation. How accurate is this?
How complicated are the financial barriers and start up costs with regards to opening a solo practice? Would it be helpful to be a hospital-employed neurosurgeon/academic hospital for the first 2-3 years of your career and then invest those earnings into a solo practice?
Finally, what are the barriers with regards to visa/permanent residency a surgeon coming from a jurisdiction such as Canada would face with regards to opening a solo practice in the USA? How can they be best overcome?
Thanks again.
I do not have a PA that I pay. Most of my patients strongly prefer the surgeon who will actually be doing the surgery. They specifically come to me because that is my reputation, whereas many of the other practices have the midlevel providers or residents seeing most patients. It can be a mixed bag regarding financials. They tend to demand $100-250k, depending on their competence, the market, or naivety (had one kid who thought he'd make $300k straight out of PA school). Likewise, the contract can vary as well e.g. incentive etc. They are helpful to assist, and can pay some of their own salary by billing for them as the first assist. Likewise, if they see patients in clinic, they bill for those services. Division of labor is what you decide as the supervising surgeon. They can do anything you are comfortable with supervising them to do. Some hospitals have restrictions e.g. PA can not take primary trauma call or can not independently see new consults etc. Also, many hospitals provide a midlevel to help in the OR and another to cover the floor to incentivize you to bring your cases there. Thus, the work-flow for a practice PA, at least in my practice, was limited.
The level of call is multifactorial. True, I am on call for my office 24/7, unless I arrange with a colleague to cover me. I pick as much call with the hospital as I'd like, which currently, is zero. The former can be a major hassle. Setting patient expectations, and pre-empting questions so they don't call, really helps. I do not prescribe narcotics except periop, so Friday night refills are not a thing for me. In my experience in PP, the hospitals per diem for call is decent, and can be a nice path-to-retirement plan. That is, you get $1-6k/night to hold the pager. For the risk of having to operate a total of 4 times a year overnight for a slow hospital, that can be a pretty safe bet. The ER call can help build a practice, as you have more spoon-fed consults, and interact with a wider array of other doctors.
The financial barriers are pretty simple. Everything costs money, and you make nothing when you are straight out of training. No one will give you anything for free. Taking a hospital employed job or a job in a group can be a way to start practice. Be wary of non-compete clauses in contracts. Moreover, it is infinitely harder to give up the sure money to take a leap for the unknown. Likewise, "investing" can create equity, but liquidity is often much needed in solo-practice. Budgeting in your first year or two with the AR and PL is going to be significantly guess work. Having a reliable income stream is helpful and there are numerous ways to accomplish this.
As a Canadian, opening a solo practice in the US would present the same barriers any potential immigrant/alien business owner has. If you would like a perm visa or green-card, many critical need hospitals will do this as part of their incentive to have you come. Moreover, if you work "for free" e.g. just taking the call per-diem, it's beneficial to them. That being said, they don't "own" you that way, and often aren't interested. I was born a US citizen, so my knowledge of the requirements is rather limited to what I've noticed or heard. It might be worth asking someone from your program or cold-calling a young surgeon in your area who did this. Often, we look to help one another.
As a pgy3 considering PP, you are my hero
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