Private Practice Career Options. Society for Academic Emergency Medicine Planning for Starting in Practice Lecture Goals Provide residents with some

Private Practice

Career Options

Society for Academic Emergency Medicine

Planning for Starting in PracticePlanning for Starting in PracticeLecture GoalsLecture Goals

Provide residents with some practical advice on Provide residents with some practical advice on specific things they should do in their last year of specific things they should do in their last year of residency to prepare for post-residency medical residency to prepare for post-residency medical practicepractice

Present a timetable to follow in the last year of Present a timetable to follow in the last year of residencyresidency

Help residents avoid financial and legal Help residents avoid financial and legal entanglementsentanglements


Planning for Starting in PracticePlanning for Starting in PracticeLecture OutlineLecture Outline

Choosing among career optionsChoosing among career optionsChoosing a communityChoosing a communityPreparing a Curriculum Vitae (CV)Preparing a Curriculum Vitae (CV)InterviewingInterviewingEvaluating job offers and contractsEvaluating job offers and contractsObtaining a state license and hospital privilegesObtaining a state license and hospital privileges


General Categories of Post-Residency General Categories of Post-Residency Career OptionsCareer Options

Private practicePrivate practiceAcademicAcademic"Mixed" private practice and academic"Mixed" private practice and academicGovernmentGovernmentMilitaryMilitary"Migratory""Migratory"Do another residency or fellowshipDo another residency or fellowshipTake a year off and do something elseTake a year off and do something else


Academic vs Community

Academic Start at $150K plus

strong benefits Mean salary: $180K High job security

Community Start at $180-240K plus

variable benefits Mean salary: $240K Variable security

Society for Academic Emergency MedicinePrivate Practice Career Private Practice Career OptionsOptions

Solo practiceSolo practice

*Buy an existing practice*Buy an existing practice

*Start a new practice *Start a new practice

*Start a sponsored practice*Start a sponsored practiceJoin an established single doctor practiceJoin an established single doctor practiceJoin a group single specialty practiceJoin a group single specialty practiceJoin a multi-specialty group practiceJoin a multi-specialty group practiceWork for a Health Maintenance Organization (HMO)Work for a Health Maintenance Organization (HMO)Work as a hospital based (employed) physicianWork as a hospital based (employed) physicianWork as a "free-standing" facility physicianWork as a "free-standing" facility physicianWork for a non-hospital medical companyWork for a non-hospital medical companyWork for a pharmaceutical companyWork for a pharmaceutical company


Academic- related Career Academic- related Career OptionsOptions

"Pure" academic"Pure" academic

*Clinical*Clinical

*Research*Research

*Administrative*Administrative

*Teaching*Teaching

*Some combination of 2 or 3 of the above ; also*Some combination of 2 or 3 of the above ; also

consider tenure vs. non-tenure trackconsider tenure vs. non-tenure track"Mixed" academic & private practice"Mixed" academic & private practice

*University hospital teaching service*University hospital teaching service

*Private hospital teaching service*Private hospital teaching service


Government & Military Government & Military Career OptionsCareer Options

GovernmentGovernment *Public Health Service*Public Health Service

*Indian Health Service*Indian Health Service

*Foreign based services (such as embassies)*Foreign based services (such as embassies)

*Agencies (such as the CDC, FDA, etc.)*Agencies (such as the CDC, FDA, etc.)Military (remember this includes the Coast Guard)Military (remember this includes the Coast Guard)

*Commission and active duty*Commission and active duty

*Reserves or National Guard – full-time or part-time*Reserves or National Guard – full-time or part-time


"Migratory" Career Options"Migratory" Career Options

Locum tenensLocum tenensCruise shipsCruise shipsOverseas companiesOverseas companiesExpatriate clinics in other countriesExpatriate clinics in other countriesPeace CorpsPeace CorpsInternational Medical CorpsInternational Medical CorpsMedicine Without BordersMedicine Without BordersVarious missionary and volunteer servicesVarious missionary and volunteer services


Solo Practice

Advantages*Control over staff selection

*Control over work schedule

*Control over practice finance

*Greater independence

Disadvantages*No generated income if not

active

*No partner to cover practice when away

*Tendency to feel lonely & overwhelmed


Group Practice

Advantages

*Able to diversify

*Flexible scheduling

*More social activities with other members

Disadvantages*Loss of independence

*Need to compromise

*Short end of pay scale if junior member


HMO Practice

Advantages

*Guaranteed salary

*Guaranteed supply of patients

*Less paperwork related to billing

Disadvantages

*Restrictions on care plan and specialty care

*Income may be tied to utilization

*Lower salary income


Company physician practice

Advantages*Limited hours

*Limited patient

Disadvantages

*Company policies


Buying a practice

Advantages

*Established facility, staff, policies

*Established income source

*Old medical records

Disadvantages

*Cost of purchasing a practice

*Facility, staff, policies may need updating

*Clientele may choose a different facility


New Practice

Advantages

*Ability to design facility to meet your needs

*Ability to hire staff that meet your standard

Disadvantages*Start-up Cost

*Uncertain initial income

*Greater initial time commitment

*Need to write policy manual & job descriptions


Remember:

The mission of a community hospital is patient care (not education, not research, not academics)

So, patient care and clinical productivity will ALWAYS be the top priority


Factors to Consider in Choosing a Community General economy and economic stability Local government (if it is supportive of medical practice) Zoning considerations for office location Crime rate Housing Schools Stores / shopping Recreational opportunities & facilities Local road system & transportation accessibility Distance from family or friends Presence of religious congregations of your faith Ethnic considerations Spouse or significant other happiness


Sources of Information if You are Unfamiliar with the Community

Local Chamber of Commerce State bureau of tourism Physician phone listings in the Yellow Pages Speaking with a local bank manager, realtor,

school principal, pharmacist, or religious leader

Visit during different seasons of the year


General Rules for Preparing a CVGeneral Rules for Preparing a CV

Prepare a separate cover letter for each position for which Prepare a separate cover letter for each position for which you are applyingyou are applying

Make sure all your major accomplishments are listed Make sure all your major accomplishments are listed accurately and completelyaccurately and completely

Do not embellish, exaggerate, or analyze aspects of your Do not embellish, exaggerate, or analyze aspects of your historyhistory

Be honest, thorough, complete, accurate, and conciseBe honest, thorough, complete, accurate, and conciseMake sure an activity is listed for each major time period of Make sure an activity is listed for each major time period of your career (don't leave any time gaps)your career (don't leave any time gaps)

Don't include too much detail about activities or awards Don't include too much detail about activities or awards before you went to college (unless they are medically related)before you went to college (unless they are medically related)


Important "Nevers" About a CVImportant "Nevers" About a CV

Never submit handwritten CV'sNever submit handwritten CV'sNever have the CV printed on non-standard size paper Never have the CV printed on non-standard size paper (other than 8.5 by 11 inch paper)(other than 8.5 by 11 inch paper)

Never use such things as copied pages from medical Never use such things as copied pages from medical specialist directories, telephone book listings, or staff specialist directories, telephone book listings, or staff directory listingsdirectory listings

Never submit a CV without a formal "cover letter"Never submit a CV without a formal "cover letter"


Curriculum Vitae Sample Format

Personal Data (name, address, telephone, cell phone, email, fax)

Education (collage, medical school, residency) Post-residency Work Experience Medical License & Certifications (dea, state, boards, acls,

apls, atls) Professional Organizations Publications & Presentations References


Items to Leave Out of Your CV

Your religion (especially if it might affect your working hours)

Your sexual preference Personal health problems Disabilities Particular reasons you may have left certain

positions in the past


Considerations About Interviewing

For most positions you can expect to have two sequential interviews (the first is just to establish interest and compatibility and the second is for resolution of specific and detailed questions about the job and practice)

Get a decent suit (and have a “back-up” suit incase the first one gets something spilled on it)

Pre-study any available documents about the practice and the community

Bring copies of your CV and any published articles


More Considerations About Interviewing

Arrive early with an empty bladder Try to meet at least briefly most of the members of

the practice and the office staff Don’t order the most expensive item on the menu

for interview meals Send a thank you letter to each of the main

interviewers


Contract Negotiation Principles

Take the attitude that you want to be fair about the negotiations Don’t bring up any surprises, hidden agendas, or misinformation

during the negotiations Ask for everything you want at the beginning of the negotiations

(don’t bring up major new demands late in the negotiations) Don’t let yourself be forced into signing a contract in haste before

you have had a chance to review it with your lawyer Make sure all the major clauses in your letter of intent are described

in detail in the contract Expect that you will need to compromise on at least some minor

points (the best contracts are ones where each side feels they have gained something from negotiation)


Items You Will Need to Compile to Obtain Hospital Privileges

Application form Application fee or first year of medical staff dues Copies of medical school diploma, residency

standing or completion, DEA certificate, state license, National Board exam scoresheet, letters of recommendation, malpractice insurance verification, specialty board certification or eligibility, and list of medical procedures you have performed


Suggested Timetable12 months before start date

Review the geographic area in which you are interested

Obtain information on your geographic area of interest

Identify and notify ED’s in the area of interest


Last Year of Residency Planning Timetable: Twelve Months Before Start Date (cont.)

Start scanning the employment advertisements in the major journals of your medical specialty. Directly investigate any outstanding job opportunities. Even at this early date, you and the advertising practice may wish to make a commitment to each other (generally though you should not commit quite yet unless the offer is absolutely what you have always wanted).


12 Month Timetable (cont.)

Contact the state medical licensing board and request an application for a medical license (in most states this can now be done through an on-line application process through the state medical licensing board’s web site)

Contact the telephone company in the communities in which you are interested to obtain information about a listing for the following year in the Yellow Pages.



Contact the appropriate local government organization to obtain information on getting a business license for that location.

Consider attending seminars on practice start-up and reviewing other written information on the general aspects of starting in medical practice.



If you are going to start a new practice, consider hiring a practice management consultant at this time to assist in setting up the practice.

With your spouse or significant other, decide up the specific important items you would want included in your initial practice contract.

Write your CV and line up several potential faculty members or other physicians who could serve as personal references for your applications.



Buy a decent suit for interviews if you do not already have one.

Have some passport-sized photos of your self taken so they will be quickly available if you need them for applications. These photos can be easily and inexpensively obtained at any American Automobile Association office (scanned or electronic photos are best so you can send them by email).


Ten to Eleven Months Before Start Date

Identify a number of potential interesting positions. Mail your CV and cover letter to these positions.

Start making “screening trips” to areas you are considering (perhaps in conjunction with vacation time), even if you do not have formal interviews there yet.

Utilize secondary sources of information on practice opportunities (such as writing to the state or county medical society or chief of hospital staff, or checking ads in your specialty’s national and state specialty journals) if you have not yet identified any practice opportunities in which you might be interested.


Nine Months Before Start Date

At this point, try to narrow your choices of potential practices down to two or, perhaps, three sites.

Apply for a Federal DEA license if you do not already have one. Their mailing address is : U.S. Department of Justice, Drug Enforcement Administration, P.O. Box 28083, Central Station, Washington, DC 20005 ; 202-633-1000. You can complete the application on-line at www.dea.gov.



If you are going to be setting up your own office, begin specific searches (your spouse might have more time to do this) for office sites. At this point, this would entail contacting a local realtor, hospital administrator, and / or a leasing agent.

Start composing rough drafts of the office documents (such as the employee manual) you will need later


Six to Seven Months Before Start Date

If you are joining a group or practice already in existence, you should have a letter of intent from the group, if not a final contract, by this point.

Apply for hospital privileges. Write the local county medical society for

information on joining the society. If starting your own practice, narrow your office

site choices to two or three, and begin lease negotiations for the office site.


6 to 7 Months Timetable (cont.)

If you are building a new office, you should at this point have the office design completed and have a contract with a construction firm.

If you need a loan to start up the office, you should have applied for it by this time.

Order the furniture and equipment for your office.


Four to Five Months Before Start Date

Contact the malpractice insurance company that will be providing your malpractice insurance ; make sure that you are appropriately registered with them, and fill out any paperwork required by them.

If you are building a new office, the actual construction should certainly have started by this point.


4 to 5 Month Timetable (cont.)

Arrange for printing of your office stationery, business cards, announcement cards, open house information, and patient information materials.

Contact the medical insurance agencies with whom you will be dealing (Blue Cross / Blue Shield, Medicaid, Medicare, and state Worker’s Compensation insurance) to ascertain the proper paperwork required for registration with them.



Choose and order your office telephone equipment; make sure you are listed in the local Yellow Pages. Order any other office medical equipment necessary.

Order and organize the office paperwork and computer systems that you will need.

Once you have confirmed your practice address, obtain a Federal employer identification number (for tax purposes) from the Internal Revenue Service. You should apply through your local IRS office and request as SS-4 form.



Obtain a state employer identification number through the state employment office or labor department.

Contact the local city or county clerk’s office to apply for any necessary occupancy permits or local business licenses.

Determine if a state narcotics license (separate from your federal DEA license and number) is required, and apply for one through the appropriate state agency.


Two Months Before Start Date

Make sure the office signs and labels have been ordered or made.

Prepare a procedure manual, job description forms, job application forms, and employee policy manual for your office.

Plan the staffing schedule. Set your fee schedule. Send out preliminary announcements to the local

newspaper and county medical society newsletter about the start of your practice.



Talk to several moving companies, obtain moving cost estimates, and make preliminary arrangements for moving. If you will be hiring new employees, the advertisements should be placed by this time, and you should start interviewing prospective employees (having this arranged even further in advance obviously is helpful).

Obtain the “Tax Guide for Small Business” book and payroll withholding booklets from the IRS.


One Month Before Start Date

Finish hiring your office staff. Make sure all of the office paperwork and billing

paperwork has arrived and is suitable. Contact the local utilities companies to make sure

your office utilities have been turned on.


One Month Timetable (cont.)

Make sure the furniture and equipment has been delivered to the office and start arranging it.

Bond all the employees. Try to meet some of the physicians and referral

sources within the community as well as other people who will interact with the practice (hospital administrators, other facility administrators, and others). Attending the hospital’s business meetings or teaching conferences (as your residency commitments allow) is a good way to meet referral sources.


Opening Week of Your Practice

Have additional announcements placed in the newspaper, local newsletters, and possibly on local TV or radio about the practice opening.

Attend some local medical and civic meetings at which you may meet potential referral physicians and other referral sources.

Consider scheduling and advertising a “practice opening reception or party” to be held at your office.


Considerations About Personal Finances

Develop both short term and long term financial plans with the agreement of your significant other

Prioritize payback of your medical school loans early ; don’t buy a mansion or a Mercedes until this is taken care of

Consider utilizing a personal financial planner, or at least an income tax reviewer

Start a college fund for your kids early


General Advice for Enjoying Your Practice

Don’t neglect your family Don’t be afraid to take vacations Maintain your own health Maintain a pattern of self-education Develop at least one indoor & one outdoor hobby Get involved in your community Don’t isolate yourself from other medical professionals Be tolerant of your colleagues Respect your employees Enjoy your patients


Preparing for Medical Practice Summary

Formally and early involve your significant other in your career planning and community selection

Prepare your CV and cover letters early Develop and stick to a planning timetable in your last

year of residency Have an experienced colleague or legal counsel review

your contract before you sign Use formal planning to help you enjoy your practice


Author Credit-Private Practice Career: Jim Holliman MD

QUESTIONS


Postresidency Tools of the Trade CD

1) Career Planning – Garmel

2) Careers in Academic EM – Sokolove

3) Private Practice Career Options - Holliman

4) Fellowship/EM Organizations – Coates/Cheng

5) CV – Garmel

6) Interviewing – Garmel

7) Contracts for Emergency Physicians – Franks

8) Salary & Benefits – Hevia

9) Malpractice – Derse/Cheng

10) Clinical Teaching in the ED – Wald

11) Teaching Tips – Ankel

12) Mentoring - Ramundo

13) Negotiation – Ramundo

14) ABEM Certifications – Cheng

15) Patient Satisfaction – Cheng

16) Billing, Coding & Documenting – Cheng/Hall

17) Financial Planning – Hevia

18) Time Management – Promes

19) Balancing Work & Family – Promes & Datner

20) Physician Wellness & Burnout – Conrad /Wadman

21) Professionalism – Fredrick

22) Cases for professionalism & ethics – SAEM

23) Medical Directorship – Proctor

24) Academic Career Guide Chapter 1-8 – Nottingham

25) Academic career Guide Chapter 9-16 – Noeller

Documents

Private Practice Career Options. Society for Academic Emergency Medicine Planning for Starting in Practice Lecture Goals Provide residents with some