Transition Into Private Practice

by Daniel Simon, MD

The transition from residency or fellowship to the real world of private practice is an exciting time. You’ve been suturing eyelids at 3 a.m. You’ve examined the obligatory drunken-assault victim who’d been hit in the eye by “some dudes” the night before. (It’s never just one dude, because your patient would have been tough enough to handle that.) You’ve checked versions and ductions on the most uncooperative, screaming, thrashing, kicking and bucking 3-year-old.

Ah, the joys of residency. The time has come to leave it behind for the serenity of private practice. This can be harder than you think, though. As a newly indoctrinated private practitioner, here are some tips from my own experience that may help ease the move:

It’s free, so use it. The American Academy of Ophthalmology has a great online resource called Professional Choices (www.aao.org/professionalchoices). It allows you to search a database of job postings by location, specialty, salary, etc. It also lets you to post your own information for potential employers to search. This is how I got my job.

Go to the AAO annual meeting. Professional Choices organizes a job fair each year at the meeting (to be held in New Orleans in November 2007), giving applicants a chance to meet with practices looking to add a physician. In some cases, you’ll meet with group partners, and in others, you’ll meet with a practice administrator. Either way, wear a suit—and smile. I went in 2006 and had several interviews. Even the interviews that didn’t go well were good learning experiences.

Learn about employment contracts. There are a number of ways to go about this without going to law school. Talk to your attending physicians. They were in your shoes once and probably know a thing or two from their own experiences as private practitioners. They’ll know what to look for in a good (and bad) employment agreement (i.e., salary, bonus, vacation, and educational reimbursement) and may also have other tips to help you get hired. The academy also offers courses for young ophthalmologists on this topic. And when all else fails, just “Google” it. My education and research about contracts consisted of all of these resources, including the use of the ubiquitous search engine.

Are you a negotiator? Once you know a few things about contracts, and someone offers you one, you need to negotiate its terms. If you aren’t comfortable talking about money (specifically, asking for more), or don’t like the idea of asking for perks such as moving expenses or more vacation time, hire a lawyer to do it for you. You’ve worked your whole life to get to this point and you shouldn’t underestimate your value to a practice. A good attorney will get you concessions with value greater than your legal fees. If you’re on your own, when you are offered a contract, you should have a good idea of what is commonly offered to a new associate. Base salary, bonus structure, vacation time, paid leave for academic conferences, and the foundation for future partnership arrangements are some of the nuts and bolts. These all vary geographically, so know your market. Most practices are looking to make a fair arrangement, but make sure that what you’re asking for (and being offered) is fair—for both sides. Finally, learn from my experience and be cautious of the non-negotiator. Someone who makes a “take it or leave it” offer is more likely to be less flexible when the time comes to negotiate a partnership agreement.

Once you’ve made the decision to sign on the dotted line, take a breather. Celebrate what you’ve accomplished. You may even want to plan a trip to your new home and get to know your associates a bit. This is when I became acquainted with my new employers on a more personal level and met their families. It certainly helped to set a positive tone for the early days of my practice.

I’d also suggest taking a coding course. Some residency programs give their trainees a good education in coding, so you may not need it. I did. And I can tell you that I’ve taken three introductory coding courses now and I still don’t feel like I know that much about it. These courses always seem to have one or two elderly ophthalmologists in attendance; thus, you know that you’re not alone. Also, it doesn’t, apparently, get much easier to understand with experience.

Coding is crucial to the private practice of medicine. It is how your office gets paid for seeing patients and doing procedures; incorrect coding can result in significant shortfalls in income. Additionally, coding errors can lead to an audit—and large fines if you’ve been over-coding. Unfortunately and predictably, Medicare doesn’t give you money if you’ve been under-coding. Nobody wants to be the one you hear stories about: the doctor who coded a Level 5 for all visits and went broke after being fined, or the one who unnecessarily under-coded, depriving his or her new practice of tens of thousands of dollars in revenue. These are the extremes, but you get the idea.

Finally, don’t forget that there is still a residency, or fellowship, to finish. When you’re on your own, there are times you’ll long for the days when there was an attending by your side to get you out of trouble or a senior resident to talk to about a difficult case. Your experiences during your training will stay with you forever. Learn as much, see as much, do as much as you can while there are experienced doctors around who are willing to teach you. Once you are in private practice, even when part of a group, the others have their own patients to see. If you’re in a good group, like mine, your partners will be available to help you get your feet wet.

And when the day is done, you can trade war stories about a drunken/smelly/combative assault victim from your past, who was minding his own business and who’d been assaulted at 3 a.m. by a roving gang of thuggish dudes. “Dudes” - plural, of course…every time…never fails.