Because studies have found no association between practice size and quality of care, determining the choice that's right for you comes down to a variety of personal and professional factors.
Are physicians who practice in a large group setting better off than those who choose solo or small practices? What about hospitalists and docs dabbling in ancillary services such as physical therapy or laser treatment? Ask a dozen physicians and you'll get as many different answers. Because studies have found no association between practice size and quality of care, determining the choice that's right for you comes down to a variety of personal and professional factors.
For allergist Robyn Levy of the Family Allergy & Asthma Center in Atlanta, the benefits of solo practice can be summed up in one word: autonomy. Levy, who practiced in a two-person group for several years before going solo, likes that "you know all your patients, you know their families, you have a very close pulse on your practice." And decisions - whether related to patient care or vacation time - are up to her alone as the sole physician.
Levy believes that more specialists in particular are choosing solo practice these days because of the freedom and flexibility it offers. "As a specialist, you can really make a decision that if I am not here right now, my patients can get at least their basic needs met by their primary provider," she says. However, she notes that this might not be an option for certain specialists, such as oncologists.
Given the changing healthcare environment when he finished residency, ophthalmologist Steven Montgomery, didn't consider solo practice an option. He liked the idea of a bigger, more stable practice that offered the camaraderie he experienced in residency. "I enjoyed the ability to discuss patients and share ideas and kind of work together as a team," he says. Montgomery found what he was looking for at Shepherd Eye Center, a seven-physician practice in Las Vegas.
Anuj Gupta, MD, of Peachtree Orthopaedic Clinic in Atlanta, agrees with Montgomery about the benefits of a larger practice: "There's a much more collegial atmosphere - if you have a question or a problem with a particular patient, there are numerous other physicians in the office that you can bounce ideas off, and I think that equates to good medicine."
Before joining his current 24-physician practice, Gupta was part of a two-person group and briefly practiced solo. While he concedes that a small practice has the benefit of making decisions more easily, he adds, "I would have to say that it's a very, very small advantage."
In contrast, Gupta says a large practice offers some major business advantages. "First, you get to pool your resources in order to hire professional management, so that it takes some of the burden of managing a practice off of the shoulders of the doctors," allowing the physicians to concentrate on seeing patients. "Second," he continues, "it allows you to pool your resources and collectively put together ancillary income, such as surgical centers or MRI centers or physical therapy."
Of course, the other side of the coin is that in a group practice you've got more decisionmakers who have to buy in to the idea. "Yes, I see it as a benefit to be able to provide [ancillary services] if everybody's on board with it ... but there are individuals in the practice that don't necessarily see that vision of having to spend money for upstart services in order to realize the financial gain," says facial plastic surgeon Lee Kleiman, whose Annapolis, Md.-based group practice, ENTAA Care, offers laser hair removal and skin treatments. He admits that the up-front costs for the laser equipment were an obstacle to getting some of his 10 partners on board.
Kleiman, who estimates that a third of his practice is dedicated to elective procedures, has no immediate intentions of parlaying his laser skin care center into a full-fledged "medispa" - a facility that offers spa and salon services in a luxurious setting - largely because it would mean selling his partners on a whole new business model. Until then, he says, "I don't use the term 'medispa.' I say we offer spa-like services in a medical setting."
Another advantage of being in a large practice is the collective bargaining power it allows its physicians. For instance, says Gupta, "If you have a group of doctors who are bringing a hospital a lot of business and the hospital is not providing you with the services that you need to take care of your patients, then you have much more of an ability to negotiate with the hospital to provide those services."
Christina Kennelley, administrator of the Shepherd Eye Center, adds that the economies of scale are a major advantage of larger group practices. "If you have a one-physician practice, you have to have one person who's an expert in billing, one person who's an expert at the front desk, and one who's an expert at coding and possibly a surgery scheduler. If you're in a multiple group practice, you don't have to continue to hire one of those people for each physician - you can recognize efficiencies." And having multiple specialists under one roof means offering patients more services within the practice.
The hospitalist movement
Since the mid-1990s, physicians have had yet another practice option - they can work as hospitalists, physicians who treat only inpatients in a hospital setting. There were 8,000 hospitalists in 2003, and there are projected to be 25,000 in 2010, according to the Society of Hospital Medicine (SHM).
"Your typical hospitalist is maybe a couple years out of training" with a background in internal medicine, says Steven Liu, MD, who started the hospitalist program at Atlanta's Emory Eastside Medical Center about five years ago. Part of the appeal for younger docs is that working in an inpatient setting is what they're used to. "That's what you've been doing for the past four years when you're in residency," says Liu.
Another draw for Liu is that as a hospitalist he can put his critical-care skills to use. "I went into it because I enjoy taking care of sicker patients ... I can do a lot of procedures and see results quicker," he says. The downside, however, is that you may never see your patients again. Liu adds, "One of the things I miss as a hospitalist is the patient care follow-up."
For physicians who want to make an impact beyond caring for patients, many hospitalist programs offer incentives for inpatient physicians to take on clinical administrative tasks, such as joining task forces and committees on best practices for patient care or improving emergency services throughput, for example. "Hospitals typically had to bully people into doing these sorts of things, and it's becoming more commonplace for hospitalists [to be involved]," says Liu. "I think a lot of hospitalist programs are doing both clinical duties [and] working with hospitals to improve operations."
For all the pros of hospitalist practice, Liu does acknowledge that there are also cons. "The biggest con I've seen within the hospitalist movement - and it's not something we're proud of - is communication," he says. On admission and discharge, communication is paramount between the outpatient doctor and the inpatient doctor, and it's an issue hospitalists are actively working to improve.
The bottom line
While the general belief seems to be that solo physicians have less income because they aren't generating revenue when they're not in the office, allergist Levy has discovered that isn't exactly true. "The reality is that you can be a little bit busier before you leave town and when you return, so that it almost evens out what you might do in a month," says Levy, who employs a physician assistant (PA), a practice manager, six nurses, three front-desk employees, and an administrative assistant.
Physicians in group practices, however, believe that they are coming out ahead financially. "I probably spend fewer hours working in this practice than I did in my previous practice, and I'm still making substantially more money," says Gupta.
In general, hospitalists' earnings are comparable to - and in some markets slightly higher than - general internists' compensation, according to SHM surveys.
Many physicians base their choice of small versus large practice on which one allows them to better balance work and family life. "The reason I went into ophthalmology is because I did plan to have a family, I wanted to have time to spend with the kids and have some after-hours and weekends available," says Montgomery, a father of four. Even now as a practice owner, "most evenings I'm home with my family," he says. "I imagine that if I were in solo practice, I'd be going over all the billing after-hours and all that. ... For me, I'm glad I chose this direction."
Hospitalists' hours - which Liu compares to ER physicians' - may attract physicians. "For the most part, it's shift-based," he says. "So when you're on, you're on and you're very busy, but when you're off, you're off. That's probably one of the biggest differences between us and an outpatient physician." While scheduling practices can vary by group, says Liu, "I think for most hospitalists that join up with a more established group, typically the work schedule and loads are conducive to a [balanced] lifestyle."
Specialists such as Levy may rely on PAs or primary care doctors to cover for them when they are away from the office, but for the most part, larger groups have the advantage when it comes to taking call. "I spend less time on call; I don't spend as many evenings and weekends in the hospital, but I'm always very comfortable that my patients are being well cared for by my partners when I need it," says Gupta.
Levy admits that it takes a commitment to their personal life for solo practitioners to achieve balance, but her advice holds true for hospitalists, solo, and group practice physicians alike: "The secret is to never think of yourself as indispensable because you know what? Then you will be. And no one pays that price more than you."
Abigail Green can be reached via firstname.lastname@example.org.
This article originally appeared in the June 2005 issue of Physicians Practice.