Opportunity in Private Practice

[a-med-student]

Hi all,

I'm a currently a second year medical student contemplating the intimidating decision of choosing a field of medicine (in between my studying and preparation for boards, that is!). I know I still have plenty of time to decide, and I still need to rotate through the different fields and hopefully find the right "fit" for me. However, I know I have a strong preference for a field where private practice is an option. I don't come from a family of doctors, rather from a family of business owners. The possibility of working to run an efficient practice that takes great care of patients is really my ideal scenario.

My question for you all is this - what fields and practice models still offer good opportunity in private practice? If you're in private practice, what is your set up and do you think this will be sustainable?

My understanding is that some specialities that rely on compensation from procedures that may be subject to future cuts (ex: GI with colonoscopies). I've also learned a lot about the DPC movement in primary care, and specifically its rejection of the insurance-driven high volume model. However, I'm unsure of the DPC movement's viability in an environment moving towards massive health systems.

I know that following my interests and finding a field with the right "fit" clinically will be very important. I'm confident that my medical school education will give me good exposure to the clinical side of the various fields. However, I'm not sure I'll get exposure to viability of private practice in the various fields. Thus, I'm asking you. What fields appear to have a future where private practice will be viable?

Thanks in advance for your time.

[ENT Doc]

They all will, but each will face different pressures requiring different business models. Focus on Step 1. Otherwise your decision will be made for you.

[The White Coat Investor]

I would avoid a field like EM, where even if you own your job, that business is basically dependent on a single client/customer/contract. Lose the contract, the business dissolves. The only exception is a free-standing ED owned by the docs who work there.

I suspect anesthesia, radiology, pathology, hospitalists, intensivists are in similar boats.

The less you have to do with a hospital, the better for you to get what you're looking for. But bear in mind that many truly private practices are having a rough go of things lately.

[q-school]

Derm
Plastic surgery
Urology
Ent

[wideopenspaces]

I think outpatient psychiatry will always be good because there is very little overhead if you don't take insurance. You need an office space and that's pretty much it.

[MPMD]

Very difficult to predict this kind of thing reliably and it would be low on my list if I were counseling you in specialty choice (which is something I do, a lot).

When I was a student applying to EM I had this non-low grade anxiety b/c it seemed like everyone I knew wanted to do EM and I just didn't see how the job market could take it. The job market is just fine and shortages continue to be predicted.

There are so many dominoes that need to fall before you end up in true private practice that I just wouldn't worry about it. There are amazing fields out there where basically no one is truly in PP. Some of it depends on how you define that. Many EM docs work for a group that contracts w/ a hospital but I'm not sure I would call that true PP.

[SValleyMD]

No way would I ever touch a private practice cardiology group right now- so cross that off imo

Remember it’s not always within your control of how successful your business is with all the things that can tank your practice from above. But obviously some can still thrive in today’s or any environment so I applaud the guys that try.

I would imagine a non-hospital based specialty would be best... derm, psych, outpt pain, Ophtho

If I was a business-minded entreneur type I would focus my studies/effort towards learning about stand alone procedure labs, mini hospitals, consulting business, etc but I’m so clueless On all that stuff and many of those things can be wiped out with a stroke of a pen too..

[Slav4ikMD]

If you are at all interested in psych (and it is certainly not for everyone and I would NOT do it JUST because of business opportunities), then consider it.

"Psych is the new derm."

[tex]

The White Coat Investor wrote:

The less you have to do with a hospital, the better for you to get what you’re looking for.

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+1, great advice

 

[a-med-student]

ENT Doc wrote:

They all will, but each will face different pressures requiring different business models. Focus on Step 1. Otherwise your decision will be made for you.

Click to expand...

I know this is true and I'm definitely focused on Step 1. Thanks.

The White Coat Investor wrote:

The less you have to do with a hospital, the better for you to get what you’re looking for. But bear in mind that many truly private practices are having a rough go of things lately.

Click to expand...

This is definitely what I've heard and read about. Thanks WCI.

q-school wrote:

Derm Plastic surgery Urology Ent

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I'm assuming that derm and plastic have a unique place in that they can do aesthetics. Are urology and ENT successful simply because they are surgical subspecialties with good compensation for procedures? Or is there more to it?

MPMD wrote:

Very difficult to predict this kind of thing reliably and it would be low on my list if I were counseling you

Click to expand...

Valuable input, thanks.

SValleyMD wrote:

If I was a business-minded entreneur type I would focus my studies/effort towards learning about stand alone procedure labs, mini hospitals, consulting business, etc but I’m so clueless On all that stuff and many of those things can be wiped out with a stroke of a pen too..

Click to expand...

Very interesting. It seems like there are potential business opportunities out there, but they have less to do with speciality choice and more with connections and the local environment.

Slav4ikMD wrote:

If you are at all interested in psych (and it is certainly not for everyone and I would NOT do it JUST because of business opportunities), then consider it.

Click to expand...

I have definitely heard this, and it's on my radar. But as you said, I would never go into psych without actually being committed to the field. Thanks.

[Matas]

Specialties that generate technical revenue for office-based procedures or other sources of ancillary revenue.

Of course, that's based upon today's reimbursement climate. Who knows by the time you have finished medical school and residency/fellowship training.

[CM]

.

[ENT Doc]

ENT is successful because, as WCI alluded to, you need the hospital less and less as a non-academic ENT.  More and more is being done at surgery centers vs hospitals, and more and more is being done in-office vs surgery centers.  The focus is shifting away from the hospitals.  The less you need them, the more leverage you have with being paid for call, etc.  Plus, ancillary services such as allergy, audiology, hearing aids, speech pathology, in-office scanners, etc. are successful strategies for additional income.  It's also better for medicine and patient care - lower cost to the system, and a one-stop-shop that is more convenient than hospitals are.  The key is also how dynamic your specialty can be given any reimbursement changes.  Think the same margins yield success if colonoscopies or EGDs get reimbursements dropped?  The more dependent you are on one procedure, the more idiosyncratic risk you have and the higher long-term risk.  I heard a podcast about an oral surgeon who had built her entire practice around lip ties.  That's a recipe for long-term failure.  Diversification, like with investing, is key.  May ride high one day, but then crash the next.

[FIREshrink]

Psych has the lowest rate of medicare acceptance and one of the lowest rates of insurance acceptance of any specialty. if you enjoy the field and working with a certain kind of patient you can make a good living, be your own boss, be largely free from the influence of hospitals, insurance companies, and EMRs, do a lot of good, and have a great work life balance.

[Slav4ikMD]

I'll make another pitch for psych here - NOT at all convincing you, but some additional factors to consider, in addition to what FIREshrink already mentioned - huge need with tons of jobs and rather high locums hourly rates (great to supplement other things you may want to do), salaries are not what they used to be and have separated themselves from lower paying specialties like peds, opportunities for loan repayments due to need, opportunity to have a direct pay practice (especially in certain areas), can have a "micro practice" where you are a one man show with nearly zero overhead vs build a larger practice where you can also hire therapists, do cool things like TMS, etc.  Basically sky is the limit and there are many different things one can do within the field and it is pretty easy to mix and match as well (also to mix employed and self-employed opportunities which is favorable in a number of ways).  And it is genuinely very rewarding in many ways.  I have a feeling you will pick something else, but just wanted to give you the info.