Transitioning into primary care practice

By Bruce D. Armon, Esq. & Marianne Nikas, M.D.

The first year of any job can be an exhilarating and eye-opening experience. There are daily doses of excitement and apprehension. In addition to the clinical challenges, the first year of practice is most likely the physician’s initial exposure to the “business” of medicine. This article provides insights for smoothly navigating the transition from resident or fellow to successful first-year primary care practitioner.

Take advantage of your last year of training. Too often, the last year of a residency or fellowship is dominated by a series of distractions. This includes the anticipation of finally being able to earn a decent living in a few short months, paying down some of those exorbitant student loans, the inevitable separation from the friends you have made during the past few years and the exhaustion from reaching the end of the long educational road.

This is not the time, however, to doze off during grand rounds. Be a sponge when it comes to keeping apprised of clinical developments shared with you by your attending physicians. Pay attention to the instructions you receive regarding accuracy in coding, medical record documentation and risk management. Keep informed about the changing health care laws and regulations and understand the way they will impact you and your colleagues. There is no time like the present to learn and for you to become a leader in your profession. It will not only make you a better clinician, it will make you more attractive to your current and future employers. In addition, the additional knowledge will provide a substantive bridge to help you effectively cross into the world of the “business” of medicine.

Research the practice you would like to join. Like any prudent shopper, you should have a good understanding of the dynamics of the practice you would like to join. When interviewing, talk with your supervising physicians, your peer physicians and the support staff. Each will play a key role in your transition to private practice. You should feel comfortable working with them and their professional capabilities. Gather a sense of whether the staff and employed physicians are happy with being a part of the practice. Inquire from its principals about the history of the practice, including its physician and staff turnover, and the projected future of the practice. From a parochial perspective, learn what your role will be in the practice and their expectations of you in detail. Many of these expectations should be delineated in your employment contract.

Understand what your employment contract permits and prohibits. Once you have begun negotiations with your first employer, make sure you are comfortable with the provisions of your employment contract before you sign the contract. In most cases, you have more leverage before you sign the contract than after you are employed by the practice. There is no such thing as a standard first-year physician employment contract. If your employer makes you promises during your interview, make sure these are accurately reflected in the contract. Compare notes with fellow graduating residents and don’t hesitate to ask advice of experienced physicians, including those you met on your interviewing circuit.

Understand the “fringe” benefits the employer plans to provide to you. For instance, if your prospective employer has a disability policy for its physicians, get the details regarding its provisions and date of onset. Does it provide short-term and long-term disability? What constitutes short-term and long-term disability? What percentage of your salary do you receive while on short-term and long-term disability? Do you have any out-of-pocket expenses related to the policy, including taxes on the benefits? Can the disability policy be used for maternity leave, or does the practice have a separate maternity and family leave policy?

There is an old, but true, cliche for employment contracts: the devil is in the details. What a contract says, and doesn’t say, can go a long way towards impacting your happiness during your first few years of practice. If a dispute arises regarding a provision in your contract, you will be held to the terms within the “four corners of the contract.” Be aware of the terms of the restrictive covenant, non-solicitation clause and liquidated damages section of your contract. If you do not understand a section or a sentence in your employment contract, talk with someone who can assist you in resolving your questions and clarifying the contract’s language before the contract is signed. Finally, keep a copy of your signed employment contract and every policy and procedure bulletin referenced in your employment contract, including your benefits information.

Become a participating provider. Your colleagues in your practice should assist you in completing the voluminous paperwork required to be a participating provider with every managed care plan and other third party payor plan in which the practice participates. Many practices may have an officer, manager or practice administrator who can handle this task. It is incumbent upon you, however, to stay actively involved in your credentialing proceedings because your ability to see patients covered by a managed care plan will be dependent upon your being a participating provider in that plan. If your employment contract has a productivity quotient or the ability to earn increased revenues if you meet certain criteria, you especially want to make sure there is no delay in getting your credentials completed with a managed care plan because this could have a direct effect on your take-home pay or bonus opportunities.

Understand the role of managed care in your community. As a primary care practitioner, you will be one of the gatekeepers to specialty care in your community. This is not a responsibility to be taken lightly. Talk to your colleagues in your practice to gain a better understanding of which specialists they refer their patients to, and why they choose one specialist versus another. As you become a more seasoned physician, you will likely develop your own referral base of specialty physicians. Maintaining relationships with these individuals, and ensuring that your patients are pleased with your choice of referral, is very important. Sending your patients to a specialist who cannot see them in a timely manner or may not have the same approach to patient care as you do is the easiest way to sour a patient relationship. For example, one patient may appreciate a specialist’s strict advice and become inspired to take a more disciplined approach to their disease. Another patient may feel offended by the same specialist’s stern manner.

Meet the doctors in your community. As you look to develop your own specialty referral base, take advantage of opportunities to meet the specialists in your community. Attend physician meetings at the hospital(s) where you have admitting privileges. This can be a wonderful way for you to become known and to meet the quality doctors in your community. Take a leadership role in a medical committee which is of interest to you. Become active in your county medical society and in other non-medical aspects of your community. There are many ways to meet your local physician colleagues. To maintain the high quality of patient care you personally provide and the trust of your patients, you need to be comfortable with the specialists to whom you send your patients. This is also a valuable way to hone your networking skills and create opportunities for growth or collaboration within your community.

Respond to being second-guessed by your patients. The evolution of information technology, particularly the Internet, can dramatically increase the knowledge base of your patient population. Depending upon the computer-literacy of your patients, they may be more inclined to tell you what they found while “surfing the web” the night before their appointment. Do not feel threatened by the amount of “medical” information available to consumers. You should, however, ask your patient where he or she retrieved their information and then reiterate your conclusions regarding the course of treatment. In many respects, the more information a consumer has at their disposal, the better patient they may become and bigger advocate for your services.

Successfully move up the seniority ladder. As you become a more experienced primary care practitioner, you will likely assume more leadership positions within your practice and your community. Depending upon your practice, a partnership opportunity may be near, or far, on the horizon. Before you get there, learn as much about the “business” of medicine as possible. You need to learn more about the various third-party payor reimbursement formulas, the revenues and expenses of your practice, maintaining a private practice in general, and keeping apprised of the changing health care laws and regulations. The latter may impact you and your practice’s ability to be successful business people. Of course, you must also maintain your clinical expertise and good relations with your patient population.

In a seemingly short period of time, you will become a senior attending physician in your practice and community. Then you will have the opportunity, and responsibility, to mentor a junior primary care physician’s transition from a residency or fellowship to private practice. The cycle never ends, you just switch places.

Bruce D. Armon, Esq., is a member of the health care practice group of Saul Ewing LLP in its Philadelphia office. Marianne Nikas, M.D. is a first-year family practitioner in private practice with Pottstown Family Care, in Montgomery County.