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Solo vs. Group vs Hospital Employment

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  • Solo vs. Group vs Hospital Employment

    I'm a Cardiology fellow starting to look at future employment options.  For the longest time I always said I'd want to be hospital employed as I had no business inclination or interest in running a practice, I was (and still am) ok with some decreased autonomy and dealing with minor politics, my personality can handle those things.  However, I've heard some bad experiences from attendings employed by hospitals, it has been a bit eye-opening, but maybe I had just been naive.  I'd consider a group practice, but having dealt with bad co-workers before, I am hesitant of the potential politics and disagreements that could happen in that setting as well.  I'd certainly be open to the idea if it were a group of physicians whom I knew and trusted.

    However, now I'm actually considering the idea of a solo practice, is that crazy in this day and age?  Everywhere I read about practices, especially cardiology, that are moving to hospital employment and it seems that most are happy with it.  Is hospital employment as bad as some attendings made it sound?  Is it truly too difficult to make it as a solo/group practice that hospital employment is the only way to survive?  If I do go solo, I think I have some options that would make it an agreeable option.

    I figured those here at WCI are a practical, experienced and astute group, so I'd be curious to hear other's thoughts on this.

  • #2
    Solo is getting harder every year.  In just one small example, you need a lot of IT support to submit MACRA data to CMS in order to avoid penalties. This is onerous, next to impossible, for solo physicians.

    Joining a large multi specialty group or being employed by a hospital allows you to practice medicine and avoid the business hassles.  However, large groups or hospital employment may sometimes be overly focused on metrics and productivity. If the data analysts are overbearing, watching your practice patterns over your shoulder, it takes away from the joy of being a physician. Most physicians are happiest when they can focus on quality human connections and compassionate care for patients.


    • #3
      If you start solo cards, you can make it, but prepare to hustle hard for a few years. I have a family friend who did this in a very competitive market and is doing very well, but they sacrificed family time and sleep for a while before being able to hire help and transition to a more sane life.


      • #4
        Quality of life is a huge factor. A buddy of mine opened his own practice and in the last 8 years has taken a total of 2 weeks vacation, and as an employed physician in a hospital owned group I take 5 weeks per year. Granted, I have very little say in how day to day operations are taken care of, but it's all a trade-off, and you'll have to decide what's more important to you.



        • #5
          No choice is perfect. You are going to have to decide what you're willing to negotiate with yourself and your family.

          Willing to work hard for a few years and then be your own boss with huge earning potential? Go solo.

          Willing to trade off autonomy for the safety net that a group provides with the possibility of future higher earnings? Take the middle ground.

          No risk tolerance? Don't want to deal with employees? Not very organized? May need to seriously consider the hospital.

          You need to know yourself, your limits, and your ambitions to make this choice. Talk to others you trust before you make a firm commitment. I don't think you should make your decision based upon isolated experiences and the opinions of a few squeaky wheels (not referring to forum members  ). Do your due diligence.
          My passion is protecting clients and others from predatory and ignorant advisors 270-247-6087 for CPA clients (we are Flat Fee for both CPA & Fee-Only Financial Planning)
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          • #6
            Within the three categories, there are some models that work better than others. Each opportunity should be investigated in its own merit, not dismissed because the model is not your first choice. In cardiology, I have colleagues that are happy and unhappy as solos, as part of a group, and as hospital-employed.

            "I was (and still am) ok with some decreased autonomy and dealing with minor politics..." -- You say that now, and I expect that is the case, but you will not feel that way in ten years. I guarantee it. These are the things, more than variations in compensation or workload, that will get under your skin and trouble you over time, like the little stone in your shoe that is no bother for a block or two, but if you had to walk ten miles with it, you would go crazy.


            • #7
              If you like total control go solo. If you want to be told what to do work for a hospital. Some groups are very fair to newcomers some are not. It may be tough to go solo in the future. Some patients really prefer a small practice. Many pros and cons and I am typing this on my phone


              • #8
                Solo practice in a specialty expected to take hospital call can be a brutal lifestyle, and if you don't take call it's hard to build a referral base. The business of medicine is becoming more stacked against the solo doc every day as well. It can be done, but not easy.

                Deciding between a private practice group and hospital employee depends much more on the particulars of the contract than on the group model. Preferring a private practice model doesn't mean much if the job offers you are getting expect q2 STEMI call with a 5 year pre-partnership track. I would cast a wide net, interview with a variety of groups, and pick the offer that best matches what you want for your career and your home life.


                • #9
                  Being employed by an institution was crushing. I want to make the decisions about my work life, not have them imposed on me. The autonomy and the direct performance incentives of solo practice are invaluable. I would never go back.

                  That said, I'm sure the above responses are a lot more relevant to cardiology than my experience is.
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                  • #10
                    I did solo OB for about 25 years.  I shared call with other small or solo groups.  I had some bad experiences out of residency with a big group.  I have liked the total control of my schedule.  The mind set is different because you know you have to deal with the problem and not sit on it until the morning when someone else is on call.  To do solo you have to be comfortable with cash flow management and managing an office staff.  You can go on vacation but you have to have good relationships with other docs in your community.


                    • #11
                      Solo in primary care is still possible and one can earn as well as groups or hospital employed but in a specialist position, soloists are a dying breed.

                      Overheads are high. The new rules on EMR / MACRA is onerous and draining on your budget. And ignoring it means decreased reimbursement. When you go on vacations ( and you must, for your sanity) the overhead of paying the salaries of the staff and expenses of keeping the office open with no income production can cost a pretty penny.

                      Hospitals have bought up FP and internists and they refer to their own specialists. Hence your referral base shrinks. The on call can lead you to be struck with indigent patients and patients with poor insurance.

                      There are some large groups that contract with the hospital and function as the only physicians in that specialty who are affiliated with the hospital. Basically a hybrid between a independent group and hospital employed. That might be a good option.


                      • #12
                        I do think starting a solo practice would be hard to do now.  I am basically ignoring EMR/MACRA and plan to retire if it effects my income enough.


                        • #13
                          Especially in cardiology, the economic cards are stacked in favor of the hospital and against the cardiologist.  If you look at reimbursement over the past 20 years, you will see that physician reimbursement goes down slightly most years; and if lucky it stays stagnant; and only very rarely we get a 0.5% increase.  Whereas hospital reimbursement has gone up 1-2% just about every year.  So now compounded over a couple decades, the hospitals basically get huge amounts of money, and physicians very little.  My hospital owned cardiology group "loses" several million dollars a year, but the hospital cardiovascular service line (which includes my cardiology group as a cost center) is very profitable.  Because of this, the hospital is able to pay us a larger salary than we could make on our own.

                          MedAxiom data shows that this is true nationwide.  Owned cardiologists have an average compensation that is about $100,000 above a private practice cardiologist, and the owned cardiologist does about 1,000 RVU less than the private practice cardiologist.  I'm sure being your own boss has huge intangible benefits, but data suggests it means you will have to work 10% harder to make $100K less.

                          Now there are big tax benefits of owning your own practice that I have learned about here at this website.  So tax burden likely is less than as a W2 employee.  I don't know enough to know how to calculate that into your equation.


                          • #14
                            Cardiology was decimated by reimbursement changes. Private practice cardiology was eviscerated. If you go that route it will be very hard. Make less and take lots of call.

                            Kind of the opposite of what most people here seem to want.

                            Do you have a specific geographic restriction? If you are free to move about, chances are you can find something that suits your tastes.

                            Good luck.


                            • #15
                              I will be doing solo private practice as soon as I can. Can't stand large organizations and I could never work for a large AMC or VA. But I'm in psychiatry which is much more amenable to solo private practice than cardiology.