Private practice medicine will soon become extinct

I’ve written previously that the days of the private practice physician are numbered.

A detailed piece from the New York Times confirms the exodus.

Young doctors, who are burdened with medical school debt exceeding $150,000 are opting for the financial stability that a salary from a hospital-owned practice, or a large integrative medical center, can bring. Gone are the days where a solo practitioner can hang a shingle and practice in a small office, or in days past, a room adjoining their home.

Today, there’s too much bureaucratic paperwork and insurance hassles to deal with. Combined with increasing costs and downward pressures of reimbursement, doctors are loathe to take a risk of essentially running a business in this toxic environment.

Some are puzzled by this. Dr. Gordon Hughes, chairman of the board of trustees for the Indiana State Medical Association, says, “When I was young, you didn’t blink an eye at being on call all the time, going to the hospital, being up all night. But the young people coming out of training now don’t want to do much call and don’t want the risk of buying into a practice, but they still want a good lifestyle and a big salary. You can’t have it both ways.”

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

There is a downside, of course. By divorcing new doctors, already naive to the business of medicine, from administration, they are going to have less clout in the decisions that affect their professional futures.

But that’s a trade off that some would make in order to have a more balanced lifestyle, which makes the private practice physician a species growing slowly extinct.

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  • eRobin

    I think this is good overall. The VA runs this way (as far as I can tell) and it’s among the best care in the country.

  • SmartDoc

    Wrong.

    A decline in solo practice does NOT equal an extinction of private practice medicine.

    Many comptetent, well trained docs go into private GROUP PRACTICE.

    I will grant you that the young docs don’t like night calls or much work beyond 40 hours per week.

  • rezmed09

    “but they still want a good lifestyle and a big salary. You can’t have it both ways.”

    I disagree. It depends on what specialty you get into. It depends on where you live and what kind of medicine you practice. It may not be the right thing to do, but lots of docs are getting this combination of pay and lifestyle.

  • TUB

    @Psychiatry has already set this precedent.

    From thread on psychiatry:

    “Let’s not hear any comments about primary care prescribing out of their scope when the psychiatrists will not see medicaid, will not see patients they think are “too sick” or just plain won’t see any more patients. The psychiatrists (until recently when we got a couple new ones) wouldn’t even talk on the phone about a patient. This weekend I needed to ask a psychiatrist about one of their patients as I suspected trouble brewing. No one was on call for the group, just an answering machine with a message to call 911 in case of an emergency. Later patient shows up after overdose. This is a common theme all over America. Primary care is practicing psychiatry because there is no one else to do it. Believe me, we do not like it.”

    Is this the precedent that psychiatry has set?

    Medicine is a business, with it’s focus on making profits. While the elderly still remember a time when doctors and patients had a relationship, our youth don’t. Their experience with medicine is the revolving NP at the urgent care center. They have experienced no loyalty in the job market and don’t consider loyalty when shopping. Many won’t pay extra for that relationship with a personal doctor. Our youth will embrace automation, electronic visits, computer interaction where our elderly prefer being touched. Instead of the old country doctor, there will be a kiosk taking your medical history.

  • http://www.drmintz.com Dr. Matthew Mintz

    Private practice includes both solo and group practice. Both models are no longer sustainable under the current health care financing structure. However, I disagree that the days of private practice are gone. In fact, you actually may see the rise of the solo practitioner. The difference is that those in private practice, whether group or solo, will no longer take insurance. Patients will have to decide whether or not they want to get their primary health care from very large practices (whether hospital owned, government run, etc.) with limited access and customer service, or whether they want to pay out of pocket for improved access and continuity by seeing a private practice physician. Many Americans are currently reluctant to pay out of pocket for health care, especially when their premiums for health care insurance are so high. However, when they realize what those premiums will actually get them, many will start turning to paying out of pocket for primary care. Psychiatry has already set this precedent.

  • http://pagingdoctorgeek.blogspot.com Dr. Geek

    While I agree that the new crop of rising PCPs (to which I belong) contain many who are interested in limited scope of practice, there exists a growing community of current residents and young new physicians who are looking for more.
    There are multiple practice models hearkening back to the last era of medicine, before the HMO and big hospital, where patients were consumers and doctors charged outright. Whether retainer/concierge or boutique or “Gordon Moore-style,” there are many examples of physicians leaving the broken system behind and making medicine more personal, giving the patient more attention, and empowering personal responsibility in healthcare decision making, while still making what for most people is a huge amount of money (150-300k for most)

  • Family Medicine Doc

    I agree w/ Drs. Geek and Mintz. I see tremendous opportunity for the solo, small group practitioner in the next few years. Especially when 30 million more insured patients will be added to the system.

    Insurance doesn’t equal access to a physician. People still want a doctor who knows them, takes time to listen to their concerns and who is available for a same day or next day appointment. A large non-profit medical group offers 15 minute visits and likely a random doctor for acute care visits. A retainer practice or hybrid traditional/retainer offers longer visits, same day or next day appointments (which is huge for working families) – AND continuity with the same physician. The key is finding the right price point. 20-30$/month retainer would make it financially viable, but people are signing up for much higher than that (150/month). And these private docs still don’t need to take call or even do hospital medicine.

    As a young doctor starting out, I’m excited for the possibilities.

  • http://glasshospital.com John Schumann, M.D.

    Great discussion, all the key points are hit: private practice will continue to exist, but likely in more boutique (“Gordon Moore-style”) settings.

    I chose the conveniences of the big institution. The academic medical center (AMC) where I work handles all the business (billing, marketing, malpractice, hiring, etc.), and I get to worry about seeing patients, teaching, and as I accrue more wisdom, management.

    Hospitals bought up private practices in the 80s and 90s thinking that they wanted “feeders” of patients into their machines. It turned out disastrously for most hospitals, since the costs of acquisition vastly exceeded the revenue generated. Also likely changed the motivation of docs that’d been privately financed to that point.

    With the costs of running a business, the regulations, the compliance issues, and the ever-increasing costs of malpractice insurance, private practice seems to me more than ever to be an intensifying hustle for diminishing returns.

    Yet my hat is off to those with enough energy and smarts to make it work.

  • jimmyz

    Shows how out of touch Dr. Hughes is. What is wrong with having a balanced family life. I am a fourth year medical student going into Family Medicine. Most of my classmates would rather have a more balanced lifestyle than salary. It shows how medicine has matured. My father was an physician in the 70′s, 80′s when I was growing up (I am an older student) and I remember him being on call every third night or more. I don’t remember him being around much as a child. We used to eat TV dinners and watch Little House on the Prairie when he was gone, which was most nights. That is a HORRIBLE lifestyle. I say family first, then patients. Sorry Dr. Hughes, but this is a new generation in charge…..get used to it.

  • TrenchDoc

    I don’t believe most of us older docs are going to embrace the new balanced left strategy. It started with most of us giving up our hospital duties and hence the rise of the hospitalist. Now that the Iron Men are leaving the building you will see other solutions to fill the need. The patients though are going to have to get used to this. Who is going to call in their prescriptions and take their after hours calls for which they are not charged. Now I can gear back and not feel like a fuss which is what we were called when we complained. Let’s see who gets the last laugh in this case.

  • jsmith

    I tried small-group family med a few years back in Roseburg, Oregon. One Medicare pt after another, 8 am to 430 pm, then paper work until 730 pm, 5 days per week in the office, every fourth night on call, every fourth weekend on call, including for “unassigned” pts (ie indigent pts) from the ER. One unassigned morbidity obese pt with the flu got respiratory failure, wound up on the vent for a total hospitalization of 47 days. I saw her every day except the weekends I was off, when my partners saw her. Reimbursement: zero. Thankfully, she eventually recovered.(She had small kids).
    My first year salary: $132k. My second year salary: $110k. Then I quit, got a new 50 hr per week job with 17 (seventeen) weeks off per year at 130k per year.
    Private practice in family med? Forgettaboutit, at least in rural Oregon.

    • Smar Doc

      In reality a practice consisting of endless Medicare cases is not a true private practice.

      This is an underpaid federal government employment, albeit without the usual juicy federal employment retirement and other benefits, or the usual easy lazybones 9 to 5 hours government work.

      Physicians in this scenerio are incredible suckers.

  • Evinx

    Looking at the comments, it seems clear the “healthcare delivery” market is fragmenting. There will be all kinds of off-shoots – some of which have been discussed. One additional option will be medical tourism. US doctors will form + link up to practices in countries such as Costa Rica, for example. This won’t work for routine colds, but it will work for various non-emergency surgeries.

    And don’t forget that some healthcare will be delivered via the MinuteClinics, etc — it may be by NPs but it will be a healthcare delivery mechanism for quick + routine situations.

    And, there will likely be other options for healthcare delivery – some that we simply do not forsee yet – but will evolve based on the HCR coming down the pike.

  • Seve

    Good for you, Dr. Smith. I think your history echos alot of other physicians and it sounds like you found a great opportunity. And people think physicians are rich. I will guarantee you the veterinarian is making that much and more, no call, no weekends, no headaches, and best of all? Cash on the barrelhead. So is the plumber, by the way and they all have weekend ‘cottages’ in the country.

  • Outrider

    >>I will guarantee you the veterinarian is making that much and more>>

    You’re funny.

    I’m an equine veterinarian. Average starting salary in 2009 for equine practice was *almost* $38K (source: AVMA market research, and no, I didn’t forget a zero). Granted, I now make more than that, but I sure don’t make $150K and probably never will. With the exception of one surgeon, none of my equine veterinary friends are making $150K, either, including a few with 30+ years’ experience.

    >>no call, no weekends

    I’m in solo practice. That’s 24/7/365 on call, which does include weekends. I drive out to the client’s barn in all weather at all hours (Ever tried to power up an unplowed driveway at 3AM? It’s dark and slippery). I’ve been on call for nine consecutive Christmases. Clients tend to ply me with cookies and hot chocolate when they call me out on Christmas, BTW.

    >>no headaches

    See above, and don’t get me started on our high incidence of physical injuries (some chronic overuse, some trauma) or malpractice risk. We’re the most frequently sued veterinarians, and though our premiums are low from an MD’s standpoint – $3000 last year – it’s no fun when a client threatens a lawsuit, especially when the patients can be worth $100K well up into the seven figures and we’re also responsible for our clients’ safety. No, I’ve never worked on a $1M+ horse; the most expensive I see are only worth a paltry $500K or so. Don’t know what the clients are worth but I try not to allow my patients to mangle anyone.

    >>and best of all? Cash on the barrelhead.

    That’s great until you’ve euthanized a perfectly fixable patient because the client does not have $5-10K set aside for emergency surgery or referral. It’s even better when sobbing children are involved. Then there’s a game we call, “I get paid on the 5th,” or, “follow the bouncing check”.

    >>So is the plumber, by the way and they all have weekend ‘cottages’ in the country.>>

    I think I shall call my plumber and ask if I can rent his cottage in the country… that is, I would if I could afford to hire a relief veterinarian and take an actual vacation. On second thought, I already live in the country.

    Don’t even try to compare veterinarians’ lives to physicians’. Though it’s true some veterinarians earn six figures, it is not the norm in any veterinary specialty.

    Veterinarians have our own problems, but I won’t bore you with any other than a recent study out of the UK: our suicide rate is four times that of the general population (that’s about twice the suicide rate for physicians). Suffice it to say I know the grass isn’t greener… and that’s coming from a horse doc.

    Oh, and I didn’t go to medical school because I like medicine but shudder at the thought of human patients. Yuck. Dental school? Even more repulsive, but I hear the hours and salaries are excellent.

    • Seve

      Outrider,

      My brother is a small-animal vet. He grosses $2,000-$3,000 daily. You’re an equine vet. Huge difference. I grew up on a horse farm and I know how horsemen are. Most are poor trying to earn a buck at the track. They rarely do. Large animals have large $ surgeries. Small ones do not. Back to my brother he is grossing $600,000 every year. With 50% overhead he’s raking in $300,000/yr. Cash-paying patients. Not gonna pay for your dog? Fine I’ll keep him. Malpractice? Huh? Small pets are property they aren’t worth $500k. Sorry ma’m your dog died on the table. Here’s $50 replacement value. He takes week-long trips to exotic locations probably 4 times per year. His phone message says: Go to the nearest vet emergency room after hours. You chose large-animal medicine. A selfless act no doubt but you knew what you were getting into.

      • Outrider

        >>My brother is a small-animal vet. He grosses $2,000-$3,000 daily.>>

        Good for him.

        The 2009 average salary for male companion animal (dog/cat) practice owners with 15-19 years’ experience was $162K. If your brother is doing that much better, good for him, or he’s gilding the lily when he talks to you (FYI, I have no idea what my siblings’ salaries might be. Not a topic of conversation.)

        >>You’re an equine vet. Huge difference. I grew up on a horse farm and I know how horsemen are. Most are poor trying to earn a buck at the track. They rarely do.>>

        Racetrack practice is entirely different from ambulatory practice. It’s both better and worse.

        >>Large animals have large $ surgeries. Small ones do not.>>

        Well, there are those kidney transplants, total hips and cruciates, but other than those, I guess you’re correct.

        >>Back to my brother he is grossing $600,000 every year. With 50% overhead he’s raking in $300,000/yr.>>

        How is he managing 50% overhead with a clinic and employees? Impressive, but this does not represent reality for the majority of even well-managed small animal practices.

        >>Cash-paying patients.

        Cash only, huh? There’s an idea to eliminate those nasty bounced checks and “charge backs”.

        >>Not gonna pay for your dog? Fine I’ll keep him.

        Check your local laws on that.

        >>Malpractice? Huh? Small pets are property they aren’t worth $500k. Sorry ma’m your dog died on the table. Here’s $50 replacement value.>>

        Ah, yes. That’s why most of us went to veterinary school vs. medical school. Can’t say that about Grandma, for sure, but Fluffy or Rover? Sucks to be you.

        >>He takes week-long trips to exotic locations probably 4 times per year.>>

        Well, good for him. Sounds very successful.

        >>His phone message says: Go to the nearest vet emergency room after hours.>>

        Now, that’s the one small animal practice aspect I envy.

        >>You chose large-animal medicine. A selfless act no doubt but you knew what you were getting into.>>

        No, actually not selfless: I tried small animal practice first. After six months I knew if I stayed I’d probably chew off one of my own paws. I like horses. Dogs and cats are too much like people, IMO.

        • Seve

          Outrider you say here:

          “Don’t even try to compare veterinarians’ lives to physicians’. Though it’s true some veterinarians earn six figures, it is not the norm in any veterinary specialty”

          Yet you quote here:

          “The 2009 average salary for male companion animal (dog/cat) practice owners with 15-19 years’ experience was $162K”

          Which of your statements do you support? That $162k is likely right around the primary care physician average.

          http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_hc07000052.html

          Also see here:

          http://www.bls.gov/oco/ocos076.htm#earnings

          As you know, equine veterinarian earnings lag their other counterparts. Your preference is equine. Fair enough we need equine vets. It’s also on average the least paying specialty. And I know first hand how physically demanding and dangerous it is.

          All in all by your own figures, yeah $162k isn’t bad for an average salary for a companion animal vet. Not to shabby at all. I bet there are plenty of primary care docs who would kill for that kind of money.

          • Outrider

            >>Which of your statements do you support? That $162k is likely right around the primary care physician average.>>

            Sigh. Read more carefully; those two statements are quite consistent when read in context.

            Not all physicians are primary care physicians. Primary care physicians are the most poorly paid physicians. Most physicians are compensated far more handsomely than are primary care physicians.

            The average salary of $162K refers to male companion animal veterinarians with 15-19 years’ experience. Any figures on male primary care physicians with 15-19 years’ experience? If you’re interested in more valid comparison, that is.

            Furthermore, “average” means, well, average, or “mean”. In general, average salary indicates that roughly half earn more, half earn less, though a more interesting number would be median salary because outliers are less likely to skew the data.

            If your brother really earns $300K, he would be an outlier, especially if he’s been in practice less than 15 years.

            >>equine veterinarian earnings lag their other counterparts>>

            No. Actually, we’re among the highest paid veterinarians, particularly those who limit their practice to high-end performance horses (and especially those who offer acupuncture, chiro, naturopathy, and other lucrative services with questionable value, as I alluded to elsewhere in this discussion).

            >>Your preference is equine. Fair enough we need equine vets. It’s also on average the least paying specialty.>>

            Not for experienced male practice owners or, increasingly, female practice owners (of certain kinds of equine practices).

            >>All in all by your own figures, yeah $162k isn’t bad for an average salary for a companion animal vet. Not to shabby at all. I bet there are plenty of primary care docs who would kill for that kind of money.>>

            Why don’t we ask:

            HEY, HELLO!!! (sorry to shout) Primary Care Docs who have been working 15-19 years (or however long), is $162K a satisfactory salary for what you do?

            This should be interesting.

            And before I forget: would you, Seve, be happy with $162K as a companion animal veterinarian? Or would you only be interested in veterinary medicine if you were earning as much as your brother? (or more…)

  • http://www.practicemanagersolutions.com RMore

    Interesting comments. I like Dr. Schumann’s idea of boutique physicians – where you get what you pay for. It lends itself to more satisfied customers (patients).

    Most naturopaths (ND) are self pay and people are paying good money to get an alternative treatment such as biofeedback, etc. where supplements can be tested immediately to determine if the body accepts them. Local Florida holistic practitioner gets paid $275/hr. You can see less patients with this revenue. No weekends or nights for sure.

    The real boutique may be in integrating both methodologies, MD and ND.

  • Outrider

    >>The real boutique may be in integrating both methodologies, MD and ND.>>

    We already see this phenomenon in equine veterinary medicine amongst those who like the money but don’t want to work the hours or do any heavy lifting, literally.

    I think it’s unethical quackery, though it’s certainly profitable. I admire the charisma and money-making acumen of certain of my colleagues but I also like to sleep well at night.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    The first 10 years I was on salary and the next 10 years I have been in private practice. After enjoying relative freedom (how much autonomy do any of us really have?), it would be extremely difficult to become an employed physician again. The health care legislation, which I did not support, will help dry up the remaining pockets of private practice, which provides a different level of service to the public. If one of my patients calls in the morning, we add on to the schedule. If the same patient calls a corporate medical behemoth in town, they get a different response.

  • ninguem

    Hey Outrider, you don’t catch me saying that sort of thing about vets………but I am wondering. Does it make a difference if you have a large-animal practice, rich people’s horses or “investment-grade” horses, compared to, say, an urban or suburban small animal dog-and-cat practice?

    Don’t know much about horses, I prefer automobiles…….

    • Outrider

      >>Does it make a difference if you have a large-animal practice>>

      Some of the best-paid veterinarians are food animal (not equine – swine, poultry, cattle) veterinarians. Cattle veterinarians in particular work some of the worst hours in isolated regions under the most demanding conditions. They earn every penny for what is, after all, food safety and public health work. Still, producers would prefer to buy the drugs, “learn” the procedures and dispense with veterinarians. There are some nasty legislative battles currently brewing.

      >>rich people’s horses

      Generally true, though some rich people remain rich precisely because they don’t like to spend their money and/or are “slow pay”.

      If I could clone my top client 50 times, I’d clear (not gross) a cool $250K/year (or more, but I’m not greedy). Not a practical solution, unfortunately, though I’d also work in an immaculate environment on well-mannered horses with competent assistants and warm water taps. I’d also look cool and glamorous every day, rather than my alternate persona: a muddy, bloody, phlegm-spattered, tooth-root-abscess/thrushy frog-smelling farmer flunky with a limp. Oh well – not gonna happen. Besides, I’m rather fond of my 4-H kids and the little old people who own creaky old horses. I’d miss (some of) them.

      >>“investment-grade” horses

      Do you know how to make a small fortune in the horse business? Start with a large one!

      These animals shatter legs in seconds (saw a horse fracture its tibia in a stall once – not good) and colic and die within hours. Poor investments.

      >>compared to, say, an urban or suburban small animal dog-and-cat practice>>

      The small animal guys both 1. charge more for their products and services (the market currently supports this, but there’s tremendous backlash coming, in my opinion) and 2. don’t hesitate to send clients to the animal ER after hours (if the client doesn’t own a trailer, it’s not fun to locate one in the middle of the night OR safely load an injured or critically ill horse that isn’t keen on entering the trailer in the first place).

      Out of necessity, I do send clients to the nearest veterinary school center when I’m not available (funerals, CE, root canal). Not popular, and do this with the wrong person and you’ll probably lose both the client and all her friends. The horse-owning population is in communication to an alarming extent. One wrong move, it’s all over FB, IM and the bulletin boards, and you’re toast.

      Some other figures for 2009:

      Average practice owner’s salary: $159K men/$116K women

      Average associate’s salary: $103K men/$83K women

      In my earlier post, I forgot to mention the one veterinarian I know who makes seven figures. This person doesn’t practice, is boarded in a non-practice specialty, has an additional PhD, is brilliant and worked all the way up in industry like a proverbial dog.

      No easy path to riches, other than being born lucky or marrying well.

  • +dr l c sunda

    I do agree with you , a profession which is finding difficult to survive in this competitive world of other easy options for a good future & lifestyle is definitely putting up a question mark on the minds of this financially burdened generation

  • Seve

    Hi Outrider *raises hand*

    Subspecialist in internal medicine here. Been in practice 14 years. Yep! I’d be more than happy with $162k/year! You? Care to ask me any more questions as a practioner? Also would be happy to make that as a companion animal vet. Also proud of my brother who likely is in the top 5% of vet earners! Good on him!

  • Outrider

    >>Subspecialist in internal medicine here. Been in practice 14 years>>

    Didn’t you mention elsewhere you were now working in another industry/no longer in practice, or has another Seve commented on this site?

    >>Yep! I’d be more than happy with $162k/year!

    Really. So, as a subspecialist, you were making less than $162K.

    >>You?

    Do I sound unhappy?

    • Seve

      >>Didn’t you mention elsewhere you were now working in another industry/no longer in practice, or has another Seve commented on this site?

      That’s me. I’d been in practice for 14 years and left a little over a year ago. Does that make my response invalid to your query?

      >>Really. So, as a subspecialist, you were making less than $162K.

      Hmm as I recall your question was “is $162K a satisfactory salary for what you do?” and my answer was, even as a subspecialist, yeah it would be satisfactory.

      >>Do I sound unhappy?

      By the tone of your posts? Frankly, yes.

  • Outrider

    >>That’s me. I’d been in practice for 14 years and left a little over a year ago. Does that make my response invalid to your query?>>

    No. Just clarifying.

    >>as I recall your question was “is $162K a satisfactory salary for what you do?” and my answer was, even as a subspecialist, yeah it would be satisfactory.>>

    You, a former practicing subspecialist, think $162K is a satisfactory salary for a primary care or IM subspecialist physician with 15-19 years’ experience. I’m sure that would be a popular opinion to espouse to a group of subspecialists, especially since you no longer work in that field and are no longer practicing medicine.

    So, I’m curious: for what reasons entirely unrelated to salary did you leave practice?

    >>Do I sound unhappy?
    >By the tone of your posts? Frankly, yes

    How so? I’ve commented that I generally enjoy my clients, don’t envy small animal veterinarians (other than after hours emergency centers) and never seriously considered medical or dental school (people, yuck).

    But there’s no doubt I, like most of my equine veterinary colleagues, am proud of my ability to “war story” with the best (it’s a small, exclusive club).

  • Seve

    >>You, a former practicing subspecialist, think $162K is a satisfactory salary for a primary care or IM subspecialist physician with 15-19 years’ experience. I’m sure that would be a popular opinion to espouse to a group of subspecialists, especially since you no longer work in that field and are no longer practicing medicine.

    They are free to espouse whatever they deem important or unimportant to them.

    >>So, I’m curious: for what reasons entirely unrelated to salary did you leave practice?

    Lifestyle. I get 8 weeks paid vacation every year. The average physicians takes maybe 2 or 3 if that. I prefer time with my family.

    >>How so? I’ve commented that I generally enjoy my clients, don’t envy small animal veterinarians (other than after hours emergency centers) and never seriously considered medical or dental school (people, yuck).

    But there’s no doubt I, like most of my equine veterinary colleagues, am proud of my ability to “war story” with the best (it’s a small, exclusive club).

    Congratulations to you.

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