Mark Rowh

It's hard to overstate the importance of some decisions.  In the life of a physician, the choice of where to practice would certainly fall among them.

“Location can impact your daily practice, as well as your career trajectory and quality of life outside of work,” says 

, a PCP at Spring-Ford Family Practice in Royersford, PA and ACE Medical Director for Tandigm Health. “Choosing the right type of practice – large or small, independent or system-owned, single- or multi-specialty – can also go a long way toward overall job satisfaction.”

The best time for making this choice varies. Sometime during the residency seems to be the best option for most, with earlier starts allowing more time for exploration. But waiting until the third year is also acceptable if the delay is not too long, according to 

, executive vice president of Merritt Hawkins/AMN Leadership Solutions. “Given the dampening effect of Covid on the job market, it’s better to job hunt earlier in the year and not wait until you are a few months out,” he says.

Regardless of timing, selecting where to practice merits careful investigation. In making your decision, consider these tips.

1.  Don’t rule out the independent and/or small group route

Although large healthcare systems have much to offer, other possibilities may be worth considering. Independent or smaller groups may offer increased reward potential, more autonomy, less bureaucracy, greater flexibility, and an ability to limit payors, says 

, CEO of Private Health Dallas in Texas.

Of course, there can also be a downside, with the potential for increased financial risk, reduced negotiating power for contracts, reduced benefits, or fewer referrals.  But for some physicians, smaller is simply a better match. 

It may be tempting to stick with the familiar, but that can be a mistake.

"In terms of geography, think outside the box," Singleton says. "Don’t be bound by preconceptions."  Rather than limit your choices to a few areas you know, consider the qualities and options you want in a location, whether that means good schools, cultural and recreational amenities, or something as basic as safety.

, chief medical officer of VillageMD and Village Medical in Houston, TX feels identifying a work environment that's a good cultural and clinical fit is essential.  "Working with like-minded physicians is critical to long term career satisfaction," he says. If your clinical interest is in wellness and prevention, a practice with large skilled nursing or hospital obligations would likely not be a good fit. If you have a young family and specific family interests, look for organizations and locations that will give you both the time and opportunity to engage in those activities. 

Unless you’re totally on your own, any location decision should include family considerations.

“If the location is not the right fit for you and your family, that may not be the best practice for you,” says 

, president of The Physicians Foundation. “I know of physicians who had the opportunity to practice their dream job in their dream city, but because their spouses were simply not happy there, they had to relocate.” In fact that almost happened in Price’s case. He found a location and practice which seemed ideal, but his wife quickly realized that the area was almost devoid of young families.  They looked elsewhere, finding an alternative that proved to be a better fit. 

Concierge medicine and primary care: The differences

If the goal is starting a private practice rather than joining an existing one, facilities planning should commence up to two years in advance. In looking for space to lease, the search should begin 12 to 14 months ahead of the planned opening, says 

, executive vice president at Transwestern, a national commercial real estate firm.  When looking to build a new property, physicians should start the site selection process 18 to 24 months before opening This allows enough time for finding the site, negotiating the sale of the land, closing on the land, designing the facility and constructing a new building.

, medical director of plastic surgery at Modernizing Medicine in South Florida, advises supplementing research with personal insights. “Talk to those that came before as you are finishing residency,” he says.  “Ask what the landscape and journey looked like for them.” Talking to people in a community where you might want to live can also be helpful, but keep in mind that their own agendas can color the information offered. Insightful sources of info may include CEOs of hospitals in the area. “They are often more than willing to talk and will give you a good picture of the landscape,” Rosenthal says.

The American Medical Association recommends creating a checklist for investigating and acting on practice choices. Such a list might include lifestyle factors, available practice options, steps in become practice-ready and key components of employment contracts. Other resources can be found in AMA’s training module, “Choosing the Practice That’s Right for You,” at 

Articles

Regardless of timing, selecting where to practice merits careful investigation.

Deciding where to practice: Seven tips for success

Providing for the health of patients is obviously job number one in every medical practice. But what some may find surprising is that without proper attention, the same environment can pose threats to patients and visitors. In minimizing dangers, a commitment to focusing on patient safety is a must.

"To promote a culture of safety within a physician’s practice, it's critical that the practice has comprehensive policies and procedures in place to allow for an orderly and uniform approach to patient safety," says Diane Doherty, senior vice president, healthcare risk engineering for insurance provider Chubb.

Certainly, total safety can never be guaranteed. But here’s a look at some solid approaches to avoiding hazards in any practice.

Slideshows

From data analysis to violence prevention, here are seven ways for your practice to avoid putting patient safety at risk.

7 Ways to Minimize Patient Safety Risks 

When it comes to the way patients choose their physicians, times are changing.

"Patients want to go to good doctors and this, of course, isn't new," says Luke Kervin, co-CEO of Los Angeles practice growth platform PatientPop. "What is new is how they're gathering evidence to decide who is a good doctor and who is not." He notes that in the past, prospective patients might have asked their primary physician for a referral or family and friends for recommendations. Today, they're conducting their own research on websites such as Healthgrades, Vitals, and Yelp.That means attention to maintaining a positive profile is a must.

"Online reputation is critical to attracting new patients for most physician practices today," says Matthew Bates, MPH, managing director of medical group transformation at Studer Group, a healthcare coaching and consulting firm in Pensacola, Fla. He cites research showing that more than half of healthcare consumers will search online to find or check on a new physician before seeing them.

Given this realty, how can physicians garner the best possible scores? 

Online reviews are important to attracting new patients and building your practice. Here's how to become a 5-star physician. 

8 Ways to Become a 5-Star Physician in Reviews

Direct primary care (DPC) is a throwback to an earlier time, where physicians abandon reliance on insurance in favor of a direct payment agreement with their physician. They may not be traveling to patients' homes, black bag in hand, but those embracing this approach are finding that, at least in part, it offers a welcome return to the medical practice of earlier times.

"Direct primary care is a new adaptation to an old concept," says Ripley Hollister, MD, a primary-care physician in Colorado Springs, CO. "This concept is why many chose medicine as a career. They want to provide the best quality of medical care possible for their patients," says Hollister.

The DPC model is one many physicians find potentially attractive. In the Physicians Practice 2017 Great American Physician Survey, 63 percent of respondents said they would consider switching to DPC if circumstances were favorable. Before making such a move, what are some of the factors to consider? 

Here are thoughts from physicians with first-hand experience.

More than 60 percent of physicians say they would consider switching to DPC if circumstances were favorable. Here's what you need to know about the model.  

9 Things to Know Before Switching to DPC

Dawn Morton-Rias, president and CEO of the National Commission on Certification of Physician Assistants, offers this advice on how physicians can best utilize PAs:

1. Let them do their job to the full extent of their license so that you can concentrate on your patients and the practice.

 Certified PAs practice medicine. They can provide complete patient care from diagnosing and treating patients, ordering and interpreting tests and prescribing medication. Let them know the door is open and encourage them to ask questions when needed.

 Certified PAs have been successful when put in charge of practice-wide programs. Could this PA run the Annual Wellness Program in your practice, ensuring all Medicare patients take advantage of this visit? Could the PA manage group appointments for diabetic or hypertensive patients?  What about assigning the PA to work with the technology group on EHR updates and workflow changes?

3. Extend access further with early morning/evening/Saturday clinics staffed by certified PAs.

 This will allow you to serve more patients and increase revenue to your practice.

Many experts say that PAs are a good way for physicians to reduce their workload. Here are three ways your practice can best utilize them. 

3 Ways to Best Use a PA at Your Practice

Every new study seems to confirm it: Burnout is an ongoing problem in today's medical practice. The 2016 

 commissioned by the Physicians Foundation found that nearly half (49 percent) of 17,000 physicians surveyed reported feeling burnt out some or all of the time.

Burnout may result from a combination of factors including the Affordable Care Act (ACA), the introduction of EHRs, and other technology and unprecedented regulatory pressure, according to Catherine Miller, a senior risk management and patient safety specialist for the Cooperative of American Physicians, a provider of medical malpractice coverage in Los Angeles.  "Historic stressors, including medicine's culture of invincibility and the disciplined and self-sacrificing nature of many practitioners, feed into the problem," she says.  "The analogy to 'the perfect storm' is apropos."

Concurrent with growing stress levels in the doctor's workplace, the increasing availability of advanced practice clinicians brings a logical question: Can reliance on these professionals help lessen physician burnout? 

Some practitioners see significant potential for PAs and NPs to reduce the burnout problem. Others, however, are not convinced.

In an informal February survey on SERMO, the social network for physicians, respondents were asked if they believed the use of PAs and/or NPs can help in reducing or avoiding physician burnout. Fifty-three percent indicated that they do help alleviate work load pressures, while 25 percent said that they create more work and confusion. Thirty-one percent of respondents reported having had issues supervising PAs and NPs in their practice. Some 28 percent indicated that their use raised questions of who has authority in the practice, and 13 percent reported an increase in feeling territorial about their work.  At the same time, 27 percent reported that the use of PAs and NPs had a positive impact on their practice.

Those who advocate for the use of PAs point out a number of advantages.

"Hiring a PA or and NP is an effective way to decrease a physician's workload, and it can have huge benefits for the practice," Miller said.  She cites results such as improved patient satisfaction through reduced wait times and ultimately, a better patient experience.  "A few extra unhurried minutes enjoying your patient's company is good for everyone," she says, adding that less time spent on routine tasks enables physicians to focus on patients with more complex needs. 

"Reduction of work load is the number one way in which an [advanced practice clinician] can help reduce burnout," says Anthony Fisher, associate medical director of primary care for Sentara Medical Group in Hampton, Va. He cites tasks such as handling urgent-care visits, improving access by seeing see new patients in a timely fashion, and following up on hospital discharges as areas advanced practice clinicians can assist physicians. Working as a care partner with a physician to promote continuity of care can also be valuable in tasks such as educating a diabetic or following a myriad of chronic illnesses. 

William Maples, chief medical officer for the Institute of Healthcare Excellence, a collaborative of health experts in Omaha, Neb., says that along with increasing the capacity to provide care, NPs and PAs may also foster effective teamwork.

"They can help create improved relationships among all members of the team with the patient at the center of the team," he says. "NPs and PAs can model compassionate and kind care, helping the entire health care team embrace behaviors which humanize care and connection to purpose."

Maples recalls that the use of a nurse practitioner in his former oncology practice proved to be a real benefit.

"The extension of high-quality, kind, and compassionate care to our patients allowed me to have better connections with all of the patients we served," he says.  "In addition, the professional friendship of my nurse practitioner provided an avenue for emotional support in our daily work."

In her role as a NP in Porterville, Calif., Angela Vera Jackson has observed physicians being over-burdened with mounting paperwork and the increasing medical needs of aging baby boomers. She sees her work as important in allowing the physician to avoid feeling overwhelmed and consequently, less likely to suffer burnout.

"If we can attend to the less complex tasks, it gives the physician more time to allocate to patients who need additional attention," she says.

Jackson tells of a recent patient, himself a doctor, who had suffered a stroke.  The workload relief provided by her position allowed the physician to take more time with a fellow doctor than might otherwise have been the case.

Bridget Duffy, chief medical officer for Vocera Communications, a provider of clinical communication solutions in San Jose, Calif., points to the potential for enhanced teamwork.

"Organizations where doctors and nurses, both RNs and NPs, and physician assistants all view themselves as equal and valued partners in patient care usually produce better results," she says. 

Of course, as noted in the SERMO survey, some physicians are not convinced of the value of PAs and NPs in limiting burnout, at least on an across-the-board basis.

"Hiring an NP or PA to extend the skills or redirect some of the less demanding responsibilities of a physician may decrease the stress and burnout experienced by some, but may actually increase it for others," says Russell Libby, president and medical director of Virginia Pediatric Group in Fairfax, Va. and a Physicians Foundation board member.  He points out that such partnerships may bring an increase in patient visits and associated responsibilities to worry about, with less of the customary control doctors are used to having.

"Physicians expect to control their universe of work and when that gets out of balance, they can experience stress," he says. "Most will have confidence in their own judgment, but being responsible for the actions, outcomes and potential liabilities of others can be overwhelming for some."

Libby says other approaches may be more cost effective and offer greater potential to reduce burnout.  Options include using scribes to decrease the technology and data-entry burden, investing in care coordination using RNs who work to the top of their license to track and monitor complicated patients, and designing workflow models that let office staff relieve doctors from menial or redundant tasks.

Questions about quality should also be considered, according to Maples. "A NP or PA who is not qualified or has not been adequately trained can actually lead to less-than high quality care which can contribute to a further loss of connection to purpose," he says.  One result can be that work needs to be redone and connections may be strained with patients, families, or fellow caregivers.

Fisher acknowledges that some providers are likely to become territorial toward NPs or PAs if they view them as rivals for patient visits rather than partners in caring for patients. But he advocates the latter. "As medicine moves more toward a population- based compensation system, they will be vital to efficiently and effectively care for a panel of patients in a cost-effective and quality manner," he says.

For physicians who do engage APCs, Miller says it's important to appreciate the responsibilities and risks associated with their role as "supervising physician."  In the hiring process, this includes verifying the employee's experience and credentials and notifying malpractice insurers to ensure there is coverage. Also critical is becoming thoroughly familiar with state laws and regulations that clarify the authority and scope of mid-level providers and any specific requirements for physician supervision.

"NPs and PAs cannot simply be dropped into the workplace, left unattended and expected to perform," Miller says. "I've known of situations where physicians, in their excitement at having the extra help, have prematurely deployed a midlevel provider without specifically defining their scope of practice or any practice limitations." Miller has also seen lack of a proper orientation to office policies and protocols and overall inattention to adequate supervision."  Similarly, she has observed cases where physicians mistakenly attributed more clinical expertise or experience to a PA or NP than the individual actually had at that particular point in their career. In such instances not only can patient safety be jeopardized, but also the risk exposure increases for all concerned.

Miller advises gradually enfolding the NP or PA into practice and then steadily increasing his or her independence as clinical competence is demonstrated. A written agreement should be executed detailing the scope of practice and the nature of the supervisory relationship. Typical points to be covered include the types of patients the NPs or PAs can see, the procedures they can perform, mechanisms for escalating concerns about patients and emergency protocols, among other considerations.

She says an orientation for an NP or PA should cover essential patient safety protocols such as recall and tracking systems, call backs, protocols for addressing and documenting non-adherence and communicating and documenting labs.  It should also address critical results and medical advice, managing and escalating patient complaints, improving health literacy, HIPAA, and the practice's social medical policy.

"It's a sizeable task," she says.  "But providing a well-organized and comprehensive orientation serves everyone."

Everyone agrees that physician burnout is a major problem. What's less certain is the role that NPs and PAs can play in curing it.