Being in private practice makes me a better doctor

Throughout training I had an idea, and that idea was that I would be a great academic physician. I had the right training and completed research from college through fellowship. I had received research grants from medical school through fellowship, published numerous papers, and  started defining a niche. Everything was going great. Academia here I come.  Private practice was not in the plans.

Attendinghood

Then attendinghood arrived. I looked for positions in academic centers. Limited by geographical boundaries, I interviewed at 2 traditional academic centers. These sites were traditional academic centers with assistant, associate, and full professors full of R and K grants. There were students, residents and fellows. The third center was what I call pseudo-academic with students, residents, and fellows but less NIH funded research. There were definitely a lot of people producing research. It was just on their own time with various funding routes.

 

I debated between the various institutions and finally decided to go with the less traditional academic centers. Here I was a 100% clinical but with the opportunity to teach and perform research. Over the next few years I focused on my niche (cardio-oncology), practiced general cardiology, and performed the research I wanted. It was not my planned career, but I was doing the things I wanted.

 

Medical skills

Over that time my medical skills improved in some fields and atrophied in others. I was no longer dealing with arrhythmia. Why mess with hard to control atrial fibrillation when the electrophysiologist (EP) was down the hall. I did not have to think heavily regarding ischemic patients because my interventional colleagues would be happy to chime in. By being a general cardiologist at a academic center my overall cardiology skills atrophied. Sure I was great at hypertension management (better than my interventional or EP colleagues) and heart failure management (though not transplants or those requiring inotropes).

 

I was getting better and better at cardio-oncology, my chosen niche, but part of me was dying. All those years of training were fading into the ether of time. I did not mind so much as life was comfortable and easy, but it did make me a little sad. So after 4 years, I decided to move. The reasons for the move was multi-factorial but here I was, 4 years later in a new city and now in a private practice group. Not only private practice, but in a remote setting.

Private practice

So here I am now, 1 year into my new practice. Over that time I have become a better doctor. More rounded. I manage my own anti-arrhythmics and perform my own cardioversions. I decide which valve cases need a transesophageal echocardiogram and do it. Then I decide who should and should not get surgery. My skills for determining who to send an hour away for either an outpatient or inpatient angiogram are tuned. I listen to the intricacies of the history and look for the subtle changes in the ECG before sending someone for an invasive procedure. No longer having the interventionalist there for a second opinion, I am forced to make more decisions. I even am doing my own bedside echocardiograms, a skill I gave up years ago.

 

Here I am 1 year into private practice and I can tell you that I have become a better doctor. I imagine this is the case with most private physicians. We have to be more of a generalist. There is no dark corner of our niche to huddle in and forget the rest of medicine. We do not have the thousands of resources and people backing us up, allowing for us to shirk our decisions.

 

Perceptions

This is why I am surprised as to how poorly private practice doctors are seen in academics. The academicians, and honestly society, hold the academic centers up on a pedestal. It is in these houses that the best care is provided. While for some centers and more specifically some very rare or hard to treat diseases this is true, for the general, run of the mill diseases I think that private practice docs may be better off. They may provide better care with a higher continuity in that care. No sign offs or explaining what the history is to 5 other people. No students and housestaff to screw up orders and complicate rounds. In many ways, the private practice is a better place to get care.

 

So here I am now, in private practice, a more rounded doctor. I can still focus on my niche and my research if I want, but at the end of the day, my clinical acumen continues to grow. Will I ever go back to academics, only time will tell, but for now I will stay in my small hospital and enjoy fine tuning my clinical practice.

 

What do you think, are academic centers placed on a false pedestal by society? Do you prefer care at the big academic center or the big clinical center?

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DadsDollarsDebts

I am a Dad and Doctor trying to find financial freedom by owning my dollars and debts. Helping dads with their finances so they can focus on the family.

16 thoughts on “Being in private practice makes me a better doctor

  • June 21, 2017 at 8:14 am
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    I can see both sides of the coin.

    In my community hospital, I do everything that comes my way. I’m literally the only anesthesiologist in the building unless someone else is there for a meeting.

    But… in a private practice setting in a community hospital, there’s a lot that doesn’t come my way. No open hearts, heads, backs, transplants, etc… If I were in a big academic setting, I may not do many of those cases, but I would be a lot closer to it and perhaps peripherally involved.

    Of course, I didn’t want to involved in those big cases, which is why I am where I am. Tough to say if I’m better or worse off for it, but I have let some skills lapse intentionally.

    Best,
    -PoF

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    • June 21, 2017 at 8:46 pm
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      There is beauty in simplicity. I am cool with avoiding the super sick, complicated cardiac patients too. They are better served at the big centers and we send them that way.

      Reply
  • June 21, 2017 at 7:30 am
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    Very interesting, as a patient/client, I would think a private practice is better to be a client of because there’s more focus on the patient. The doctor can’t rely on the institution and its brand, and instead, must rely on his own competence.

    Sounds like a good combo of private practice and then going to the big centers for some mega issues is the right call.

    I go to a private practice out of familiarity and comfort.

    Sam

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    • June 21, 2017 at 8:43 pm
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      At the end of the day, the trust with your doctor is the most important aspect of care. Feeling that they will respond and have your best interest at heart is key. The combo is a good way too go, but often the advertising leads people to think that the big centers are the best. That is not always true.

      Reply
  • June 18, 2017 at 12:12 pm
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    Interesting thoughts and ideas, and something I used to think about when deciding on where to train. Certainly in academic hospitals you get a whole host of experts, those who know and can recite data and papers off the top of their head. For super-specialized care, they are likely the best bet (more so due to the nature of rare diseases and super-specialists needing to work in academic centers to have a job), but I’ve also seen/heard of academic docs who are out of touch with “real-world” medicine or technically weak, that a private practice doc would be better suited. Likewise, there are private docs out there who are top-notch clinically, but then are those who are out of touch with the most up to date medicine. I’ve seen some horribly run community private practice hospitals, as well as bad outcomes in resident-run hospitals. In the former, there just seemed to be a lower quality of doctors practicing and a lack of organization, structure and a patient-care culture. Whereas the resident-run hospitals, things would fall through the cracks, get missed, etc. due to inexperience or lack of oversight. Academic hospitals fortunately (and maybe unfairly) have the benefit of cheap, around the clock, MD-caliber labor, which allows to them to put more funds and resources into other aspects of patient care. For me, it’s not so much private vs academic care, but more so overall hospital quality of care.

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    • June 18, 2017 at 9:22 pm
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      It is definitely an interesting question…where to train? I think if you know you are going into private practice, then it does not matter. You should go to the place you will get the best clinical training.

      If you don’t know what you want to do, or definitely want to be in academics, then going to the biggest named academic center is the way to go.

      No right or wrong on that end, just planning for your future. My goal was academics so I trained in the best places I could and then when I decided to go into private practice it was a easy transition.

      Reply
  • June 17, 2017 at 5:36 am
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    Great article DDD! I had honestly only considered an academic career up to this point. This gives me a lot to think about. Thanks!

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    • June 17, 2017 at 6:49 am
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      Thanks Future Proof. I thought I was academics for life, but then made the switch. So far so good. Who knows where I will be in 10 years though.

      Reply
  • June 15, 2017 at 1:52 pm
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    “Many academics are smug and think that private practice doc just focus on money and don’t read the latest literature, which I don’t think is true.”

    Ha-ha, we lawyers have very similar conversations about our private practice vs. the academy.

    Except your academicians at least truly provide real-life, substantial value.

    Whereas ours get summer stipends to do “research” so they can put out “scholarship” with dreckish titles like, “The Open Road and the Traffic Stop: Narratives and Counter-Narratives of the American Dream?“.

    (rolls eyes)

    Reply
    • June 15, 2017 at 9:03 pm
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      Interesting. You know I have never thought about academics vs private practice in law. I just imagined everyone went out to private practice. That academic gig sounds awesome. I would love a stipend to do “research”. Thanks for checking out the post.

      Reply
  • June 12, 2017 at 8:53 pm
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    I just did a simulator course at an academic center and it was impressive to see the academic attendings roll off the reasearch from paper after paper.
    The weird thing is I remember a lot more going wrong in residency that in private practice. I don’t know if that is just because a bunch of inexperienced residents are running around sabotaging the attendings or if the attendings have a lot of book knowledge but not much hands on real world situation knowledge.
    I am glad we have both. Patients can tailor their care to where they feel most comfortable and the research available in academic institutions is invaluable. I enjoy getting things done efficiently and on my own in a private practice setting but ocationslly teaching a medical student or nurse is also fulfilling. I just don’t think I could take it every day. 🙂

    Tom @ HIP

    Reply
    • June 12, 2017 at 9:34 pm
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      I did not even mention the residents. Very true that they can mess things up. Still a balance is key and makes sure that there are docs available for all types of patients.

      Reply
  • June 10, 2017 at 4:14 pm
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    Great topic. Many academics are smug and think that private practice docs just focus on money and don’t read the latest literature, which I don’t think is true.

    Another issue is that many academics spend half their time or more doing non-clinical work (meetings, research, conferences, more meetings). I’d rather have a doctor who sees patients 5-6 days a week versus someone with million dollar grants but only sees patients one day a week.

    -WSP

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    • June 10, 2017 at 8:45 pm
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      Ah to be smug. Private practice breeds good docs and for run of the mill stuff they are great. For the super rare stuff, going to the academic centers is a good idea. Hopefully none of us will need these docs in the future…to good health and a good life!

      Reply
  • June 10, 2017 at 9:05 am
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    I view private practice specialists—cardiologist, radiologist, gastroenterologist, etc—as somewhere between a primary care physician and academic specialist. (Full disclosure: I am a private practice radiologist.) They possess more knowledge about their given specialty compared to a PCP, but they are not so specialized in their small academic niche that they lose sight of big picture for a given patient.

    Take a pediatric neuroradiologist. In most large academic centers, they will exclusively interpret brain and spine imaging on children. If, for example, they come across an abnormality in the adjacent chest or abdomen while looking at a spine study, they may be less well equipped to evaluate it compared to a more general radiologist.

    For reasons like this, there will always be a need for different levels of specialization. One can’t be a knowledgable subspecialist in everything, especially given the ever-increasing complexity of medicine.

    Take care,
    Dr. C

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    • June 10, 2017 at 8:34 pm
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      I whole heartedly agree. There needs to be multiple levels of specializations for each field. For me, as a general cardiologist, I find I am better rounded then I used to be in academics. If, however, my child had a rare brain issue, then of course I would want to go to a super sub-specialist or two.

      Reply

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