By Bruce D. Armon, Esq. & Mac Patterson, M.D.
To successfully “survive” the transition from residency or fellowship to specialist in private practice, you do not have to outwit, outlast or outplay your colleagues. Many tips for primary care practitioners, e.g., taking advantage of your last year of training and understanding what your employment contract permits and prohibits, apply as well to specialists making the transition from a residency or fellowship to private practice. There are, however, other specific tips which specialists should keep in mind so they, like their primary care colleagues, can be successful practitioners.
Appreciate the distinctions between academia and private practice. Most residency programs and fellowships pay little attention to life beyond the completion of the educational training process. Many academic institutions are becoming more sensitive to the financial bottom line because of their own monetary struggles. Consequently, residents and fellows are at least tangentially exposed to fiscal realities and need to remind themselves that most private practices are driven by both excellence in clinical care and profitability, not just the former. Many specialty training programs spare no expense in training their physicians. Most private practices, and the non-academic hospitals with which they are affiliated, are not training facilities. The partners in most private practices expect their new hires will be able, in a relatively short time-frame, to handle the demands of private practice with limited daily supervision.
Realize you are a fungible commodity. Despite the excellence of your undergraduate and medical school achievements, and first-class training and success in your residency program and perhaps fellowship, understand that there are many similarly suited colleagues searching for the same employment opportunities. Your pedigree notwithstanding, a private practice looking to hire a new junior physician wants someone who is compatible with their personalities and practice philosophy, and willing to work on as many of their terms as possible.
It is not realistic to expect to rewrite your entire employment contract. It is very realistic, however, to make sure you are treated comparably to your peers in the same specialty in your geographic region and that you understand the implications of all of the terms in your employment contract, including the business expenses for which you will be reimbursed. Communicate with your peer residents and fellows regarding the terms of their employment offers and compare the “apples” to “apples” of your offers with someone who understands the relevant distinctions.
The executed contract provisions will govern your professional existence in the first job and, depending upon the scope and duration of the noncompetition and nonsolicitation clauses, these provisions could have a long-lasting impact on your ability to successfully practice in a particular community. Be an advocate for yourself, or have someone advocate on your behalf. Do not assume that the private practice will be unable to find someone to fill their job opening if they cannot come to terms with you.
Decide if a big or small practice is best for you. There is no best size specialty practice to join. Bigger is not always better and smaller is not always a successful route to partnership. A large specialty practice may have an extensive staff support network to assist with billing tasks and other administrative chores so the specialist can focus on clinical issues. There may be many senior physicians to learn from, and in front of you from a potential partnership perspective. Specialists in a small practice may have the ability to earn a larger income than colleagues in a larger practice because the practice has less overhead expenses. However, the small-practice specialist may be on-call more often than the specialist in a larger practice because there are simply fewer people to share the call responsibilities. A specialist in a large practice may have an easier time scheduling vacation than a small-practice specialist for the same reasons.
Know the market and marketing opportunities. As a specialist, deciding what community to join can be a difficult decision. If the practice you wish to join is the only practice with your specialty in the community, or has exclusive privileges at the local hospital(s), you may be entering an excellent opportunity. If the community you would like to be in has several of your specialty practices, this could mean the local marketplace is thriving and needs multiple specialty practices. If things do not work out as planned with your first employer (subject of course to the noncompetition and nonsolicitation provisions mentioned above), this could be an excellent opportunity to take another position locally. The multiplicity of practices could also mean that several of the practices are struggling financially and may not be viable for many years to come. As a new doctor, it is incumbent upon you to perform due diligence and gain a good working knowledge of the strengths and weaknesses of the local marketplace.
In addition, inquire about the marketing efforts of the practice you would like to join within the community. Successful specialty practice marketing is two-fold. There is the general name identification of the practice and its physicians. However, direct patient inquiries to specialists are becoming increasingly rare in the era of managed care networks and preapproval requirements. A specialty practice can make a name for itself with the primary care practitioners in the community. The way to do so is relatively straightforward: good customer service. Does the specialist view the primary care practitioner as their partner in providing high quality care? Does the specialty practice return phone calls promptly from the primary care practitioner? Can a primary care practitioner’s patient schedule an appointment from a referral in a timely manner? Are the primary care practitioner’s patients satisfied with the care they receive from the specialist?
Understand the referral relationships of the practice you wish to join. Unlike a primary care practice where the patient is the only customer, a specialty practice has two customers—the patients and the primary care practices who refer their patients to them. The primary care practice referral network can be the lifeline or death-knell of a specialty practice. A new physician seeking to join a specialty practice should inquire about the referral relationships the practice has developed. Specialists may think they are top-notch in the services they provide patients. However, if the primary care physicians in the community do not concur in this clinical assessment or there are unresolved personality issues between the practitioners or the primary care physicians’ patients have complained about some facet of the specialists’ services, the specialists’ negative reputation will be a significant obstacle to overcome.
The Anti-Kickback statute makes it illegal to offer or receive anything of value to encourage the referral of business, and there are no Safe Harbors protecting an inappropriate referral relationship between physicians. A prudent physician looking to join a specialty practice should inquire about the specialist’s primary care practitioner referral base and learn as much as he or she can about all of the primary care practitioners in the community and the commitment of the referral relationship.
Realize that the Internet is a tool, and a distraction. Similar to primary care practitioners, a specialist’s patients may discover all sorts of “creative” remedies for their ailments. For instance, one patient suggested that chemotherapy was not a preferred course of treatment for his cancer. He suggested, based on his Internet research, that an extract of saltwater obtained from the Barent’s Sea be injected in his femoral vein. Aside from the obvious malpractice issues which this may present were the specialist to have adopted the patient’s advice, a specialist needs to remember that patients have access to greater amounts of sophisticated medical knowledge, and quackery, than ever before. A well-researched patient can be a physician’s best advocate, or second-guesser, depending upon the source of their new-found knowledge. Stay apprised of new medical developments in your specialty.
Utilize good billing practices as the first step to compliance. Most residency and fellowship programs do not spend sufficient time explaining the CPT coding processes. As a specialist, you will most likely use a discreet set of codes for most of your patients. Learn these codes and the protocols for deciding which code is most appropriate for a treatment option. Understand the billing distinctions for coding between a new patient versus a consultation. Work closely with the practice’s billing person or outside billing company to make sure your “superbills” are completed accurately and match with the documentation in the patient’s medical record. Learn the billing rules for the various third-party payors with which you are a participating provider. Ignorance of the legal rules for billing is not an excuse for non-compliance.
A specialist transitioning from a residency or fellowship to private practice faces many of the same issues as a primary care practitioner: job venue, employment contract issues, and general lack of knowledge regarding the “business” of medicine and working for a medical practice. In a managed care environment, a specialty practice will not have an established group of patients assigned to them like primary care practitioners and will be largely dependent upon primary care practitioners for its patient referrals. Choosing the right place to work and surviving as a new specialist in private practice is not nearly as difficult as surviving the Australian Outback. Plus, believe it or not, the long-term rewards are much greater.
Bruce D. Armon, Esq., is a member of the health care practice group of Saul Ewing LLP in its Philadelphia office. Mac Patterson, M.D. is a first-year hematologist/oncologist in private practice with Chester County Hematology/Oncology Services.