Evaluating Prospective Employers

In trying to determine where to send your CV, your first attention should be to the size of the organization where you want to work. No other single factor has as much impact on the early private practice success of a physician coming out of a residency or fellowship.

Solitude

You may have what it takes to strike out as a solo practitioner. What it usually takes is a deviant personality, the inability to get along with others, the need to make all your own decisions for better or for worse, and the confidence (ego) to believe you can succeed all by yourself. Seriously, the popular wisdom — that the day of the solo practice of medicine is over — is simply not true. Some of the most efficient and happy physicians we’ve seen practice in this mode.

If a physician is a superstar, solo practice may be the best way for him or her to work. Our observation is that solo practices are more efficient than group practices, operating at lower cost. They are also more sensitive to the physician’s leadership (or lack of it). For the physician willing to take a lead in describing what he or she wants from practice, a solo practice will respond to the owner’s management touch more rapidly than a group practice can. For complete freedom and independence, solo practice can’t be beat. Soloists aren’t bound by the constraints of consensus among colleagues in decision making and don’t have to pay for the management layers a larger organization requires.

Solo practice can be professionally lonely, though. Cross-consultation must be more formally (and inconveniently) arranged. The same is true for coverage. When solos are in town, they tend to cover all their own call. And when they leave town, their practices are covered by a competitor, leading many to stay home. This fact contributes to the higher incomes of many solo practitioners: They work harder than their colleagues in groups.

The good news is that all physicians are smart enough to become a success in solo private practice. We generally recommend, though, that physicians seriously entertaining the notion of solo practice should do it after having worked in a group practice. Physicians can learn a lot about the workings of an office — both the things you wish to replicate and the things you wish to guard against — by working in someone else’s practice. Residencies don’t usually fill this educational need, though some fellowships may. A well-run private practice setting is the best place to try out management ideas and learn from other people’s management mistakes.

Big Groups

Big groups such as multi-specialty groups and HMOs have certain advantages. The cross-specialty collegiality and clinical stimulation may be attractive. A built-in referral network may provide you with plenty of work to do. And the community visibility that a big group may experience could give it a marketing boost in attracting patients.

On the other hand, the disadvantages of multi-specialty group practice are manifold. Because they are larger organizations, they are harder to manage than smaller, single specialty groups. They require a professional clinic administrator with the inevitable assistant administrator, and various levels of supervisors just to operate. All of this is costly and, in unenlightened hands, chaotic. We often find physicians working in this environment exhibiting an “employee mentality” regardless of their ownership status. The “nine-to-five” attitude is often hard to shake in an environment that restricts the individuality of the physicians and forces them into an essential bureaucracy.

Splitting the income of the multi-specialty group is always embroiled in controversy, too. There are many ways of computing who gets what, but someone will always feel it is unfair. This leads to an inherent instability that takes energy to overcome. Sometimes, it cannot be solved, leading to some of the more spectacular examples of the shifting of wealth from physicians to lawyers.

Small Groups

The single specialty group of more manageable size — say three to five physicians — is a very popular way to practice cardiology. The single specialty group can support its own non-invasive lab, as well as other clinical programs that the solo practice or the small cardiology department in the multi-specialty group might not.

Group practice institutionalizes the call coverage routine and the professional stimulation of colleagues in your same field make it in many ways a more desirable mode of practice than being solo. But don’t mistake easier coverage arrangements for a way to get more time off. You pay for your thrills, and when you take time off you can expect it to come out of your income. Many physicians recruit junior associates as a way of “getting more time off without losing income.” While this strategy may work in the short-run, it never works in the long-run.

Single specialty group practice can also give physicians the security of a formalized buy-out arrangement in the event of death, disability, and normal retirement. Our experience is that physicians in single specialty groups earn more than physicians in multi-specialty groups, too. On the other hand, they often earn less than physicians in solo practice.

The principal disadvantage of the single specialty group is the “magic number” problem, which is bound up in the notion of manageable size. Two physicians practicing together is probably the worst number for joint practice because in the absence of one, the other cannot do the work of two. A group composed of three physicians often works, since two can easily handle the work load of three for short bursts of coverage. (Beware the myth of the three musketeers, however, since we often see decision making in the three-physician practice falling into the “two against one” category). Four or five physicians can often work well together.

But by adding a sixth physician, many practices go “critical.” Covering for five or more physicians on call can mean a grueling weekend. And, the practice’s management may no longer be able to cope with this increased level of activity. The larger number of personnel required may put too much of a supervision burden on the traditional office manager. This size practice is too small, however, for the clinic administrator/supervisor style of management. And, the size of the office space needed may mean a costly expansion, move, or the addition of an otherwise marginally justifiable satellite office.

Our tentative conclusion: Stick with three to five physicians in single specialty group practice. If you are about to be the sixth or seventh physician, be prepared for big problems.

All of these alternatives settings are valid choices for some physicians. We see contented, fulfilled, and successful physicians in each of them. Matching the setting to your own personality and goals is the trick. What it takes is some thought and introspection — and a little luck.

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