Should I stay or should I go? The hidden questions involved in choosing a practice model
Editor's note: This article was originally published in the June 2012 issue of YPS Perspective in Plastic Surgery News
Should I stay or should I go?
If I go it will be trouble,
If I stay it will be double.
C'mon and let me know,
Should I stay or should I go?
– The Clash
"Should I Stay or Should I Go?"
To join, remain in or leave a plastic surgery practice is obviously among the most important, challenging and delicate decisions young surgeons will make. Those just leaving residencies and fellowships are often ill-equipped to know how best to decide on practice models, usually having received no formal business training or "real world" education on the economics and medico-legal aspects of running a business or dealing with employees.
Group practices - with their promise of expense- and employee-sharing, camaraderie, call coverage, economies of scale and breadth of scope - can be very attractive environments, particularly for a young surgeon just starting out. Obviously, however, any group of individuals doesn't always agree on important practice matters; therefore, a solo practice is attractive to surgeons who favor autonomy over the advantageous features of group practices.
I work in a relatively large group, which was the right environment and set-up for my needs coming out of residency. One factor that influenced my choice to enter a group was an utter lack of readiness and fear of the uncertainties of a solo practice at that time. I recall attending the ASPS Senior Residents' Conference in March 2003 - a mere three months from the end of my plastic surgery training - and observing a panel of young practicing surgeons discussing their practice models and the decision-making process that led them there.
Earlier help, please?
Of all the things I learned, I was most struck by the fact that the guidelines for starting one's own practice, for example, suggested we should have been told these things at least 12-18 months prior to finishing, if we were considering starting on our own out of residency.
I remember thinking, "Why isn't there a Junior Residents Conference where we could have been told all this?" At that time, I was deciding between a microsurgical fellowship or moving cross-country to a group practice in a competitive-but-desirable market for plastic surgery. I chose the latter, and have been with the group for nearly eight years.
Young surgeons face similar issues in every geographic marketplace, and it's instructive to observe the phenomena that influence surgeons in their decisions. I'd like to share some of the thought process that can inform one's decision-making on practice models.
Factors such as geography, market competitiveness, opportunities for research and teaching, and cost of living are obviously important, but candidly they've been well addressed in other excellent essays on the subject of practice models. I choose to focus on what factors might make it attractive to join a particular group - or to venture into another practice model after starting with a group.
Past, present members are key
Of course, one of the most important considerations is the mix of individuals in the group. No matter how lucrative, social-media-savvy or well capitalized a business is, you won't be happy if you can't get along (most of the time) with the group's principal individuals. For example, if one or more individuals in positions of seniority don't treat junior surgeons with respect and fairness, or if they exhibit poor professional ethics toward patients or employees, it's unlikely you'll be the exception who's spared such treatment.
Such environments often have a "revolving door" of former associates who've come and gone from the practice, and it's imperative that you be able to communicate with these former partners to ascertain the factors that led to their departures. Any resistance on the part of the practice to let you communicate with such individuals should be viewed as a major red flag.
In my case, there was an associate who left the group to relocate, and the practice was candid in putting me in touch with him. Our conversation reinforced that he had an enjoyable association with the group and left for reasons related to geography, spousal preference and a desire for autonomy - all valid reasons that didn't reflect negatively on the group. In fact, the group's willingness to let me hear his perspective was quite helpful in giving me a realistic perspective. He remains friendly with all of us to this day when we see each other at ASPS meetings and appears satisfied with his decision, yet he admits that there are different challenges he faces as a solo practitioner, particularly in this difficult economy.
In my decision-making process, it was quite helpful to have an insider's perspective on what worked and what could be improved in the group environment I was considering joining, so I could make an informed choice. Unlike many other relationships, your professional relationship to a group often begins before you actually get to know the individuals, so first impressions and reinforcement by observed phenomena are paramount.
What's the employment structure?
Assuming you feel you have a good personality "mesh" with the group's surgeons, the details of employment structure and partnership opportunities are critical to assess. There are some data that the practice may not be willing to fully disclose to you from the outset - such as details regarding assets and liabilities, balance sheets and tax returns. That's understandable. But to the extent you can obtain that information willingly from the prospective employer, you should do so.
For example, a practice that's heavily leveraged for its capital investments and real estate interests may not have much discretionary funding to market you the way you might like. Similarly, the model by which the practice owners share expenses may influence your choice and/or opportunity to become a practice partner yourself, or it might involve benchmarks that you may not be able to meet in your first few years - which could leave you restless or resentful.
Knowing what your targets are for base compensation, bonus compensation and partnership is critical to setting your professional goals and deciding whether to join or remain in a group practice.
Ask principals questions such as:
- What kind of overhead does the practice run, and what exactly does that entail? How are costs split among the owners and employee physicians? Do you pay a fixed fraction of your revenue collections to the group? If you fail to meet certain thresholds, do you owe the group a refund?
- What items does the group calculate as expenses to be equally shared, and which ones are categorized individually? Some are obvious: Rent might be equally distributed among all doctors, assuming everyone uses the office roughly the same amount of time, whereas car and travel expenses are often allocated to each individual. If one doctor wants to lease a Bentley and another a Hyundai, it's unlikely they will willingly split those costs equally (and rightly so).
- What specific benefits are covered by the practice? In the case of health/dental/ vision insurance, what's the specific policy and what portion is paid by the practice? Is there a 401(k) program, and does the practice put in any matching funds as a profit-sharing mechanism to reward employees? What insurance coverages (e.g., life/disability/malpractice/overhead) or allowances (e.g., marketing/car/travel /CME) are provided?
- What revenue would you enjoy from ancillary services, such as aesthetician skin care sales, noninvasive procedures performed by physician extenders, E.R. call compensation, laser hair removal, etc.?
- What aspects of your contract can be renegotiated in the future, and how frequently?
Knowing the answers to these questions will help you truly understand how much of your generated revenue will come back to you in forms of compensation. After all, if you were to leave the group or start your own practice from the get-go, you personally would need to generate a certain amount of revenue to be able to provide yourself the same benefits and perks that your employment scenario provides.
A good friend and colleague of mine, heretofore committed to her decision to be a solo practitioner, recently called me for advice - and more or less reassurance that she's doing the right thing in staying on her own and not joining a group to enjoy a guaranteed salary and regular vacations with a built-in coverage system. Clearly, only she can make that decision for herself; I'm convinced there is never only one "right" way to practice.
What's your cost and benefit?
It's also critical to know what happens with regard to compensation and benefits if/when you become a partner, and how much it will cost you to "buy-in" to the practice. There are interesting scenarios where it might be advantageous to remain an associate on a guaranteed salary rather than an owner - ask some of your friends in solo practice in competitive markets; some of the more candid ones may lament the uncertainty of their practice's revenue in this challenging economy and the impact of that on their personal income.
If joining a practice is like getting engaged, buying into a partnership is the real marriage. Just as some engagements end without a marriage, some marriages end in divorce. It's important that you also understand what your options are in the event things in the practice don't work out how you would like.
What happens if a principal in the practice leaves, or if another chooses to retire? What will be the chain of succession and how will the departing individual's share of the practice's assets and liabilities be managed? Will the departure create disarray - or more opportunity for success? Perhaps a void will be created that you can fill. Or perhaps you will not feel the practice is the same environment you joined.
Only you can decide how such situations might influence your decision-making, but it's important to consider and discuss such contingencies as you enter any contractual relationship with the group. What restrictions or "exit" responsibilities will you have should the relationship not work out to everyone's mutual satisfaction? Restrictive covenants vary in their extent, scope and enforceability. Needless to say, the counsel of a health care attorney is essential in helping you determine what you can and cannot accept in a contractual relationship.
Finally, you may have personal reasons for a change - brought about by issues outside your professional practice or simply reflective of personal growth and evolution. Some physicians make the choice to leave medicine for other pursuits, elect to extend their education by going back to school or choose to diversify their business interests.
Healthcare models are facing historic challenges, and many practices are shutting down and becoming absorbed into larger healthcare entities. Consequently, one's decision to stay or go is not one to be made in a vacuum, but rather with due diligence, realism and adherence to smart business principles.
In the final analysis, it's most essential to get to know yourself and what really makes you click. Nobody, even your spouse, knows you as well as you do. Many believe that there are no truly wrong decisions in life - as long as you learn something from each experience. Sometimes that learning experience will change our trajectories, but sometimes it merely means it changes our mindset.
I'm often reminded of the Heisenberg Uncertainty Principle - when paraphrased, it sounds like a philosophy that stipulates that you can't know exactly where you are and where you are going at the same time. Put another way, the process of observing a phenomenon changes the phenomenon under observation.
Whatever paths we as surgeons choose for our practice models, we should be ever mindful that we enjoy the privilege of practicing a unique, meaningful, rewarding and challenging specialty, one that will continue to evolve even as our professional and personal goals do.
Every time I thought I'd got it made
It seemed the taste was not so sweet
So I turned myself to face me.
- David Bowie
Hatem "Tim" Abou-Sayed can be reached at firstname.lastname@example.org