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Single Specialty Group Practice

Melissa Perkal, MD, FACS
Assistant Clinical Professor
Yale University School of Medicine
New Haven, CT

Why Do It?

The private practice of surgery can take place in many forms and venues; solo practice, group practice, and large specialty practices are some of the many options to choose from. This column deals with some of the issues involved in choosing a group practice. First you must review the pros and cons of joining a group, before trying to choose the particular practice you want to join. There are many advantages to choosing a group practice. Group practice provides an ideal way of delivering patient care in a collegial setting that keeps you from feeling isolated. You are not the sole financial support of the group, and this allows for flexibility in your practice and the natural ebb and flow of patients. Lifestyle is generally much better in a group than by yourself. Call is shared and less of a burden. There is more personal time with partners who can cover, and many practices have members take a day (or half-day) off every week; there also may be more vacation than if you were in solo practice. Since you will generally be joining an existing group, there are not the large start-up costs of outfitting a new office. Expenses are shared within the group and administrative tasks are spread over several individuals. However, the price to be paid is that there is less individual freedom; conflicts can arise over disparity in patient care, billing, and call. Trying to find the practice that suits you best may help to head off conflicts.

Choosing the Practice
There are three primary factors you need to evaluate: the people you will be working with, the structure of the office, and the financial base of the group. Although it may sound trite, choosing your future partners in a group practice is something like choosing a spouse! Foremost you should like these people and feel comfortable talking with them. In a group you often need to trust your partner’s judgment, share equally in onerous chores (like call), and talk about difficult subjects (such as money and complications). Many states have public databases in which information on malpractice claims state actions against physicians can be checked; this information needs to be reviewed for a sense of the practice and not specifics of the cases. You should plan to meet with the group at least three times: the first to get the sense of the people and office; the second to talk about more details of the practice; and the third to talk about the particulars of the employment agreement. Toward the end of the negotiations, you may want to have a lawyer look over your agreement.

The First Visit

The first decision when going into practice, no matter what the form, is where you want to be. Once you’ve decided on a location, it’s time to look at the details of how the practice works. The first meeting can cover many of the day-to-day details of life in the practice. Many practices have more than one office, in more than one community. How many hospitals and communities do they cover? Will you have to travel to more than one location in a day? You need to find out what kind of hospital setting they work in (university based or community based, for example, and with or without residents). Will you be operating with your partners, physician-assistants or residents? You should find out the volume of cases done in a year and the spectrum of those cases. Will you be providing new expertise in an area the group doesn’t have, or will you be adding depth to an already strong group? The group should have some idea of how it will provide the cases you will be doing until you establish your own practice within the group. As you start practice, will there be a mentoring system in place so you can ask questions or even get help in the OR? It’s not easy when you first start, and it’s good to know who you can call on for help. A very important lifestyle question involves the call schedule, days off, and vacations. Is the call evenly divided, or is there a difference when you’re an employee and just starting out? How long is this differential call schedule maintained? Will you have a day off? How much vacation will you be getting initially, and how much can you eventually expect to get?

The Second Visit

Most well organized practices have an office manager who coordinates the business and personnel aspects of the group. In addition, many larger practices have a managing partner who oversees the finances of the group. Meeting with these individuals can often add to the picture you are developing of the group. The group should be willing to share financial information with you. This includes the Accounts Receivable (AR), which lets you get an idea of how timely the billing and collections are, as well as how busy the group is. Most groups have accountants who prepare Quarterly Reports, which should be available to you. You shouldn’t be surprised or put off by the possibility of having to sign a Confidentiality Agreement when you go over the group’s financial information.

Now is also the time to explore the city you’ll be moving to. Does it have the right mix of leisure activities, recreation, school, culture, and access to a larger metropolis that you want?

The Third Visit

This last visit is to really find out about the details of the financial arrangements, including disability coverage, life insurance, and health insurance. Besides finding out your own salary, you need to understand how the partners’ income is determined. There are many formulas to distribute profits fairly, and you should understand how that is done. Are the profits divided equally with some differential for productivity, or does each partner make what they earn less the cost of overhead? A good practice knows what its overhead is and can give you that information. Many groups have employment agreements that define details of the financial aspects of the practice. If there are older partners in the practice, has there been some thought as to how they will be phasing out of the practice when they retire? Many practices still have a “buy in” arrangement, and you should be very clear on how the value of the practice is calculated. There may be a “non-compete” clause in your agreement. You need to find out what that will mean if you later decide to leave the group but remain in the community. Additionally, “tail coverage” should be understood. Have proof of your prior malpractice insurance coverage (unless this is your first job from training) so your new group can review its details and make sure you have adequate protection. As well, learn what your coverage against malpractice will be if you leave the group you are about to join.

Succeeding in the Practice

After getting as much information as you can, trust your sense of who you will be working with to help you make that final decision, and then look forward to a long and enjoyable practice. Once you’re in the practice you can do several things to optimize your success. Be enthusiastic and available. Learn about billing and coding–have your group send you to one of the many excellent courses available. Meet the referring physicians; perhaps your group will plan a reception or will send announcements out. Plan to spend some time with the senior partners learning the “network;” spend some time in the physician’s lounge getting to know people. You have to be more than just a good surgeon; you need to be a good communicator. Make sure you send the referring physicians letters or call them with updates about their patients. Talk with the staff (or head nurse if your group has one) to see how you are doing. Make sure a four-month review is set up to see if you are on track and meeting the goals the partners had in mind for you. If you’re not, you’ll have time to come up with a plan to insure your success. Most importantly, try to enjoy what you’re doing!!!