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.

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

  • August 13, 2017 at 10:17 am
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    Agree with your feelings and statements. I am in private cardiology practice since 2001, small 3 doctors in group with cross coverage. Most important thing is watching your overhead, keep it below 40%, watch your supply cost against reimbursement, MA’s are cheaper then RN or NP in office. Apply efficiency and communication processes across all stations, creat patient centric culture. Never turn down new patient. It’s customer service industry with loyalty business model. Remember that and you will at top in every categories.

    Reply
    • August 13, 2017 at 7:39 pm
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      Interesting perspective and thanks for sharing. I think your group has become rarer and rarer in medicine. A private group of a few doctors, signed up to practice in a hospital but not an employee. I commend you Chet as there are many now who don’t pursue this path.

      Reply
  • July 14, 2017 at 6:55 pm
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    I think one thing to consider is that none of these changes in your skill are permanent.

    You were not born with the super specialized skills of the academic center, you learned them once, and you can learn them again. In fact, you will probably learn/re-learn them faster the second time around.

    I find many doctors look at their skills leaving training as fixed, which is just strange to me.
    I have learned many new ways to do things in the eight years since I left training.

    If we want to get better over our careers, we are going to have to try new processes, and learn new skills. I doubt I will be doing the same thing, using the same drugs in 20 years as I am now.

    So, if you want to take that job in the rural setting and knock out those student loans, go for it. You will be light years ahead financially than your big city colleagues.

    In 6 years before your kids are too old, you can move to the city and do the specialized stuff if you still feel unfulfilled in your career. It might be painful, you might have to learn some things again but you can do it.

    Just because it is hard, doesn’t mean you can’t do it.

    FYI: I am in the big city specialized job and didn’t take the high paying small town gig. That’s part of why my avatar is Dr-In-Debt and not Dr-Retired-On-The-Beach.

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    • July 14, 2017 at 11:42 pm
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      Thanks Dr-In-Debt for making some excellent points. We do continuously learn new things. At my first job I learned how to read PET imaging with flow data and now I am learning how to read CT angiograms. Not things I was seeking but as circumstances change I have too. I wholeheartedly agree with everything you say here. We can relearn and the second time it will be easier. It is just ensuring we have an adequate CV/resume to get those jobs.

      Reply
  • June 28, 2017 at 6:45 pm
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    This is a great discussion. As an academic doc, I think I should pen a “counterpoint” to this — I use quotations because I think you (and the commenters) make some valid points, but also think there are some holes in the discussion.

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    • June 28, 2017 at 9:18 pm
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      Please do. I would love to hear your counterpoints and likely agree with most (as a former academic doc)….

      Articles attract like minded people typically, so I would be psyched to have a counterpoint.

      Reply
      • June 29, 2017 at 10:05 am
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        You are probably qualified to write a counterpoint on your own given your own background. 🙂 However I’ll work on it and make sure I tag you directly on Twitter when ever I get around to finishing/posting it.

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  • June 26, 2017 at 10:16 am
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    This is an interesting post. Reading between the lines it seems that you are really trying to convince yourself of something. You make the statement multiple times that you are a better doctor as if it you had not made your point. Also only 1 year into practice is not that long. I agree with POF that this can go both ways, depending on how you define “better.” Different, yes; better, no – apples to oranges. For you, this was the right choice. However as you mention most of society has quite a bit of respect for the large academic centers, and many of the best physicians we each know individually are in academics.

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    • June 26, 2017 at 3:36 pm
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      Very true. In fact, isn’t most of what we try to do in life convincing ourselves that it is the right decision. So this post was as much a reflection on myself as it is the system.

      Agreed, for me, at this point in time, this was the right decision. Better may not be the correct word but it is all in how you define better. Is better a more well rounded physician or is better being the best person to treat a certain disorder? Both work and both are better.

      1 year is not that long. I am 5 years in total, but only 1 at a more private practice setting. Only time will tell.

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      • July 7, 2017 at 12:35 pm
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        I must disagree that “most of what we try to do in life convincing ourselves that it is the right decision”

        To thine own self be true dads dollars debts. You shouldn’t have to convince yourself of anything.

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        • July 7, 2017 at 8:47 pm
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          Dropping some zen…thank you! I concur, to thine own self be true and over the last year I have taken active steps to do such.

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  • June 25, 2017 at 7:27 am
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    This is a great discussion. Thanks.

    I’m heading off to a one year ortho fellowship at a highly academic center after training in a more private practice setting. Almost all orthopods do fellowships these days.

    I’m trying to decide between initially higher paying more rural hospital employed jobs(with loan repayment) that need a general orthopod vs private practice more specialized lower paying jobs in a bigger city. There are so many ways to look at the decision that I go in circles. One concern is that if I start in a more rural, generalized job – would I lose all of the specialized skills I learned at the Mecca? Do I lose my ability to move to a larger market some day? I get very different answers from different people. The potential immediate short term pay difference is almost double! Ugh.

    I’m sure I’ll figure it out either way. The good news is I found this group of websites before I started this process.

    Thanks again

    Matt

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    • June 25, 2017 at 8:06 am
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      My brother is one of these specialized orthropods in a big academic center. He does pretty well for him self and does some amazing cases. Congrats on the fellowship!

      My preference, recommendation, and what I actually did was stick with the specialized care first. For me it was a matter of figuring out if I wanted to stay in academics/specialized care before giving up those skills (in my case research, in your case surgical skills). Hopefully as an orthopedic surgeon you should be able to make good money either way and pay back your loans. Still if money is your focus, there is nothing wrong with going and making lots of cash in the rural setting.

      In an ideal world you would do the rural practice and get plugged in with the bigger centers to do some complicated surgeries. Hard to set up but not impossible. Good luck with the decisions. Consider making a SWOT like I did when deciding my move. .

      Reply
  • June 25, 2017 at 5:20 am
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    I think it is true that many in academics are smug. It is also true that many in private practice do not keep up. At least in my field many in academics are the big money makers (OB/GYN). I think things that make you a good doctor are trying to solve whatever the problem is. If they need a sub specialist then helping them find one. If the problem is not in your field then again pointing them in the right direction. Experience doing certain things over and over again should not be discounted. You become good at it and fast. In my community (mid-size Southeast) there is a huge cardiology group of about 25-30 docs. I feel like patients do not know who is taking care of them. When my Dad had a stent placed at age 89 it was a bad experience.

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    • June 25, 2017 at 8:02 am
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      There is a danger in those very large physician/cardiology groups of being lost in the shuffle. I am sorry your dad had a bad experience with his stent. Risks can be low for any procedure but when it happens to you or your loved ones risks become a 100%.

      I like being able to do everything and refer out the more complicated, difficult cases. I know others prefer the complicated cases and would hate seeing every hypertensive patient or heart failure patient. I guess you have to find what works for you and pursue it.

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  • June 25, 2017 at 5:09 am
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    Just graduated, now a fully trained and they tell me capable, surgical subspecialist.

    I too had to make this decision. I chose more on how much I hated the academic mindset/hamster wheel and seemingly never ending administrative oversight… And of course with $400k in debt, the money is better.

    However, there is a lot of Truth to what you are saying. Some of the most revered attendings in my (old) program couldn’t preform more than a few different kinds of procedures, if they tried. We had a guy for everything.

    The counter to this is, it’s where medicine, at least anything more than routine surgery/procedures is going. We have seen a plethora of literature coming out supporting tertiary referral Centers and volume based outcomes in the past several years… It’s real and should be noted. Only problem, there isn’t enough docs to truly enforce it.

    I’m entering the private practice setting optimistic, my training was supurb. I’ll quickly realized what I can’t or won’t** take care of. Certainly I think it’s going to be easier than doing that 4 years after feeling the atrophy of academics, hats off to you for seeing it before it was too late! Great post!

    Reply
    • June 25, 2017 at 8:00 am
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      It is true, centers of excellence make a difference. Part of the problem in establishing centers of excellence is that we are still a fragmented health care system. Institutions like the VA or Kaiser Permanente can institute hub and spoke models (like a wheel) where the smaller external centers refer to the big site for major procedures, but the majority of private hospitals can not. Depending on how health care reform goes, this may be a larger possibility in the future.

      Congrats on graduating and the new job!

      Reply
  • 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.

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  • 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

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    • 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.

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  • 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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