Divergent Paths: Salaried, Private, and Hybrid Practice

Accounting classes are not a requirement in medical school, but it might not be a bad idea, according to Elizabeth Haglind, MD, a practicing endocrinologist in St. Paul, Minnesota. “Coming out of a fellowship, there is very little training provided from a business perspective, and a newly graduating fellow is going to find the business side of things very daunting if they don’t know the ABC’s of accounting,” she said.

Haglind runs her own practice and works to help other young doctors navigate the ins-and-outs of launching their careers. Last year, she gave a lecture titled “Setting-up and Negotiating Your Clinical Practice,” which covered everything from economics to office culture. After the talk, she was approached by several fellows who were interested in starting a clinical practice, but seemed hesitant.

“Some of them had wonderful opportunities to start their own private practice. It sounded like they were getting a lot of support and already had a patient base being offered to them. To one particular candidate, the health care systems were actually saying, ‘Go ahead and start your practice and we’ll send patients to you,’ but she was nervous because she didn’t know what business challenges may lie ahead of her,” Haglind recounted.

Many physicians are not interested in the administrative or billing aspects of medicine, and thus prefer to focus on patient care in a salaried role within a larger health system. However, a number of young doctors like the idea of running a business and having a larger amount of control over their work environment. Others prefer to land somewhere in between.

“The question they need to ask themselves is how much autonomy they want in their practice,” said Haglind. She believes that each fellow needs to take careful personal inventory of their ambitions to ensure that they choose the path that best fits their personality and what they picture for their future.

A few basic options are available to endocrinologists across the salaried, private practice, and hybrid models. A salaried contract at a hospital is perhaps the most straightforward option. The physician’s role is essentially 100 percent patient care and they do not need to worry about the business or administrative details, which are handled by their employer.

In academia, a salaried role at an institution is a usually must. Researchers can pursue tenure-track professorships and see patients as a part of their studies. Clinical educators can conduct educational and research activities while also reserving time to practice, usually within the same institution or an affiliated hospital. With the demands and expectations of these positions, the added responsibilities of running a private practice on the side may not be realistic.

If a physician wishes to pursue a group or solo practice but still desires an element of research in their work, they can partner with an institution on a study. Still, most of their time is likely to be devoted to outpatient care and managing both the business and medical sides of their clinic.

In private practice, the payment model is very different. Physicians partner in the business or fund the launch of their own clinic, often through a loan. The success of the practice determines the individual income, which necessitates attention to marketing, customer service, referral development, accounting, staffing, and the other aspects of building a thriving medical center.

Although it does involve additional work, the private practice option offers certain benefits. Doctors can often set their own hours and may also shape the patient experience that they desire. There is more control over the efficiency and environment of the office, which can increase patient comfort, decrease wait time for appointments, and maximize profitability. In private practice, physicians also have a say in the rates patients are charged and can provide flexibility to those paying out of pocket or with otherwise limited coverage.

For hybrid careers, there are HMO-based positions, such as staff and group models (salaried) or in-network arrangements (private); integrated delivery systems, which include guaranteed income within a grouping of healthcare organizations with many aspects of private practice still preserved; hospital-based practices that include a combination of salaried and private activity; and government-based positions, which again combines private practice with a guaranteed base salary.

Each option involves a variety of pros and cons that undoubtedly vary depending on the location, organization, and individuals that comprise the arrangement. Fellows that wish to explore a few of these possibilities in a hands-on manner may want to try “locum tenens,” or temporary placement at locations across the United States, which can give valuable insight into the roles available to them.

Haglind feels that, although she sees outstanding fellows coming out of many excellent programs, the lack of business and financial training causes young endocrinologists to shy away from private practice opportunities.

“To be honest I think the starting tools we have are very minimal,” she said. The opportunity to shadow physicians in their private practice or to take a few business courses would certainly help, but some lessons have to be learned on the job. “It takes time to understand the marketplace, to understand the position, and to understand the patient referral pattern,” Haglind explained.

As specialists, endocrinologists need to know the primary care physicians who need their services and can send patients their way. Geographical location is just one of multiple perspectives to consider. “Once you understand that, it takes a little bit of innovation to effectively market and make yourself more accessible to those physicians,” Haglind went on.

She also encourages doctors to think about efficiency in their practice. “You may have to restructure the way the front desk is taking new appointments, the way medical assistants work, and then, moving forward, maybe consider whether you need a nurse practitioner or physician assistant.”

Although especially applicable to physicians in private practice or hybrid arrangements, Haglind’s advice can be used to improve one’s performance and job satisfaction in salaried and academic roles as well. Efficiency and referrals – or references in academia – are important to any position, and working towards these goals will help a fellow become a better candidate in their chosen sector.

But, a decision for the entirety of one’s future does not have to be made immediately upon completing a fellowship. Physicians transition between salaried and private roles regularly. Haglind did. “It’s really a process in evolution,” she said.

Factors to Consider

  • Autonomy
  • human resources and payroll
  • Amount of research and/or education involved
  • Involvement in business and administrative aspects
  • Work-life balance
  • Job market

Negotiating Tips from Dr. Haglind

  • Gather information and be prepared
  • Treat people with respect
  • Negotiate from the perspective of mutual benefit and fairness
  • Set priorities
  • Develop a strategy
  • Return to unresolved issues after most of the bargaining is done.
  • Get it in writing