A physician's practice setting determines nearly aspect of their career from compensation to work environment. While there is no one perfect practice model, the most basic choice often comes down to joining with a hospital/health system or choosing independence. Six gastroenterologists discuss the merits and downsides of employment and private practice in the GI field.
The independent perspective
Question: What are the upsides of working as an independent gastroenterologist?
Jatinder P. Ahluwalia, MD, AGAF, FACG, Gastroenterology Clinics of Louisiana (Lafayette): It allows you the freedom to mold the practice to be a reflection of you. It allows you the flexibility to adjust the schedule and make any necessary changes very quickly. Depending on state regulations such as the need for certificate of need, it also allows for the potential for engaging in other projects and entrepreneurial endeavors
Geetanjali Akerkar, MD, Digestive Health Specialists (Chelmsford, Mass.): Autonomy is the single biggest benefit. My priorities are to have input over my workplace culture, income and schedule. I like being able to work closely with my partners to set the workplace atmosphere and culture. I want to hire the people who will help me deliver the kind of care I want for my patients. I'm also able to work as much or as little as I want, to an extent. I have three children, so that level of control over my schedule is a definite benefit.
March Seabrook, MD, FACG, Consultants in Gastroenterology (West Columbia, S.C.): Gastroenterologists are very fortunate. We are involved in a specialty that is procedurally based paired with cognitive thinking. We have the ability to perform procedures in physician-owned facilities, which definitely allows for independent practice.
I also very much enjoy the business of medicine. I am in a situation where I have a wonderful administrator, great partners and a fantastic staff. My partners and I think alike and love being independent. I have been in private practice since 1991. Since then, we've acquired a certificate of need to ultimately build two centers. We are now a very high volume practice. In 2014, we performed 17,000 outpatient procedures.
Q: What are the downsides of independent practice?
JA: Starting an independent practice and working as an independent gastroenterologist requires a lot of hard work and at times extended hours. In addition, one has to become comfortable in handling all GI and liver related diseases without much of an option of discussing cases with other colleagues that may be available in a group practice or at academic centers.
GA: On a recent webinar, I heard colleagues talk about billing, coding, human resources issues and lack of a steady income as downsides to self employment. But many of these things are the exact reasons I am self-employed.
On the other hand, it can be difficult to hire new people in a smaller group. Whether adding a new physician or physician extender, it is very expensive. Additionally, the changing healthcare environment causes frequent affiliation and network shifts. As gastroenterologists, we are heavily reliant on primary care provider referrals. Being in a small independent group can be risky; it is something you must always be on top of.
MS: Certainly a larger organization would be able to negotiate better contracts. However, in the bigger scheme of things that would only cost the healthcare system more dollars, and we are going broke as it is.
But, it is still possible to work with payers in independent practice. We've become involved with the larger payer in South Carolina and formed a committee, of which I am a part of, to incentivize quality gastroenterology care.
Q: How do challenges of independence and employed practice very in today's market?
JA: The current atmosphere seems to be in favour of the employed practice model. Due to cuts in reimbursement and gradual shifting of payments to the hospitals, it is difficult to start an independent practice especially in someone markets. Also, the need to come up with upfront investment to set up a practice makes it challenging especially when compared to an employed position where the set up is already in place or done by the employer/hospital.
With increase the in employed gastroenterologists/physicians and the ACOs, there is potential for channelling of patients/referrals to physicians within the ACO. Therefore, as the number of ACOs increase, independent gastroenterologist will have to consider aligning themselves with the available ACOs.
Q: Would you ever consider becoming employed?
GA: In 2015 the advantages of self -employment are significant. Our practice works closely with the other GI group in town. We've built an endoscopy center together. Our two groups have a total of 11physicians, and we share clinical work at the hospital. For now this allows for economies of scale and better quality of life for all.
MS: I am not naïve to the forces going on around us, but I hope to say independent during my career. We already work with a hospital in our market and have a very symbiotic relationship as an independent group.
Q: How can gastroenterology fellows considering how to begin their practice decide which model is best for them?
JA: It is best for the GI fellows to review their long-term plans and assess their own entrepreneurial skills. If they value independence and control of how they practice and would enjoy learning about all aspects of a practice, then they should look at being independent gastroenterologists. However, if they want the option of walking in and out of the job and have no interest in the details of the practice operation, then they may be better suited for an employed position.
GA: I think they really have to look to themselves and what their priorities are. In medical school and residency on does not spend much time talking about the atmosphere you want to work in. Medical students know academics, but not much outside of that. It is important to gain a sense of your temperament and how you work with others. It is important for people coming out of training to find out what kind of environment they will thrive in. It might will be helpful to shadow a mentor in different employment situations. For me, I like the innovative and entrepreneurial aspects of private practice.
If you are a young fellow that wants to go into private practice, you really need to learn about billing, coding and bundling. You do not learn these things in medical school or post graduate training. The clinical aspect of medicine is still the focus, but you need to understand the economic component of medicine, as well. Educate yourself. The AGA, ACG and ASGE all offer courses to help you do so.
Many women in GI think they will be protected by working with a larger institution. I had my first child during my fellowship and then I had twins. I was able to work out a schedule and with the logistical freedom of private practice I can still spend a lot of time with my kids. Women shouldn't shy away from private practice; you just have to find the right one.
MS: It is a privilege to be a physician. Gastroenterologists enjoy one of the best subspecialties available. We deal with a lot of healthy people, have an enjoyable patient base and prevent disease. It all depends on their motivation and entrepreneurship. If you think of medicine as a job, you should be as employed physician. If you think being a physician defines you, look for an independent practice and work really hard. It is, of course, all local.
The employed perspective
Q: What are the upsides of working as an employed gastroenterologist?
R. Bruce Cameron, MD,FACP, FACG, FASGE, AGAF, Clinical Professor of Medicine, CWRU School of Medicine, Director of 
Endoscopy, Endoscopy Center of Bainbridge (Chagrin Falls, Ohio): Most employed physicians will see the immediate benefit of a larger patient volume, lower malpractice costs, lower shared information technology costs, and outside help in monitoring and complying with a highly regulatory environment. Salary may be attractive depending on how it is structured. Salary based on work RVUs is desirable as it pays you for the work you do no matter what the employer collects. If your salary is based on your collections then it also depends on patient mix and the quality of contract your employer has signed with third-party insurers.
John Saltzman, MD, FACP, FACG, FASGE, AGAF, Director of Endoscopy, Brigham and Women's Hospital, Associate Professor of Medicine, Harvard Medical School (Boston): Employment offers security of job and usually steady work. Salary is usually predictable. Hours may be more regular. Call may be less, if in a larger group. Employed gastroenterologists generally have less personal risk, as the employer is responsible for infrastructure including staff and EMR, etc.
Working as an employed physician in an academic practice also offers many educational opportunities. There is opportunity to interact with medical students, residents and GI fellows. There is opportunity to teach at all of these levels as well as to educate colleagues at local, regional and national meetings. There is the opportunity to do research and write manuscripts. The combination of all of these job characteristics makes the job more interesting and sustaining over time.
Ronald Vender, MD, Professor of Medicine, Associate Dean for Clinical Affairs, CMO, Yale Medical Group (New Haven, Conn.): More predictable work schedule, guaranteed salary, though many have productivity-based incentive bonuses. Referrals are reliable from within the group. [There are] few administrative headaches of running a business. Requirements like MU and PQRS handled by the group. "Free" EMR. Access to capital and perceived sense of security.
Q: What are the downsides of working as an employed gastroenterologist?
RBC: The major downside to an employed position comes from loss of physician autonomy. You have very little input into your overhead costs, you do not control your electronic health records vendor (often not GI friendly), and you do not control your insurance contracts. Often large hospital systems want to maximize reimbursement for E&M codes, and may sacrifice GI procedure income in contract negotiations. You do not control your patient population, and often will see larger numbers of low pay government level insurance reimbursement represented in the patient population. You may have a bonus structure that is unobtainable because of the lack of control of overhead, contracts, and patient mix.
JS: Salary is often less than independent GI MD and ability to increase salary such as by bonuses may be limited. Less autonomy over personal schedule and responsibilities. In clinical academics, there is increasing emphasis on clinical productivity over all else and thus there is little or no practical difference to being employed in a non-academic practice setting. For example, there may be no time devoted to academic activities such as education or research and incentives that are purely production (RVU) based.
RV: Less entrepreneurial, less autonomy, less direct control of the work environment and limited opportunity for ancillary revenues. Basically, there is a loss of control that those who switch from private practice to employment will experience.
Q: How do challenges of independence and employed practice very in today's market?
RBC: The independent gastroenterologist needs to protect his/her referral base and keep the practice overhead as low as possible. This is difficult to do with large hospital systems buying primary care practices and shifting allegiances coupled with rising employee and information technology costs and falling reimbursement rates. The employed physician suffers from his/her loss of autonomy. Decisions about third-party contracts, coverage, time off, EMR vendor, and employees and their salaries are all removed from their direct input to some degree.
JS: Both models are rapidly changing, so the current models of today will likely not be the same in the future. Overall the healthcare market has been one of consolidation and increasing dependence on large healthcare systems/hospitals. This will vary by region, but certainly is true in Massachusetts where it has been increasingly difficult to be in private practice unaffiliated with healthcare systems, especially for small private practice physicians. As mentioned above, clinical academics is also changing with little or no academic time in many places for faculty and RVU-based salaries and bonuses.
RV: Dependent on local markets. Those who have ASC, path labs, etc, still have opportunity for significant revenues. However, these could be significantly changed with the stroke of a pen in DC as was seen by Cardiology and Oncology. ACOs and regional clinically integrated networks may cut into referral networks significantly. Negotiating power of smaller groups likely to be diminished.
Q: Would you consider switching to a private practice model?
RV: I was in private practice for 26 years before joining a full-time faculty practice. My decision to make this career change preceded the concerns about healthcare transformation, and was not based on financial considerations (which would have kept me in practice). Rather, I was offered a leadership position which I found personally and professionally compelling.
Q: How can gastroenterology fellows considering how to begin their practice decide which model is best for them?
RBC: The dominance of one model over another varies widely across the country. Entrepreneurial fellows may find independence very attractive with input into all areas of practice, contracting and regulation. They should be wary, however, of the large mega-group that can be as regimented as any hospital system can be. An employed position may be more attractive to the fellow who does not want to deal with any of the day to day practice management issues that are so prevalent in today’s environment.
JS: Ultimately the GI fellows need to look inside themselves before they look outside. They should decide where they want to live geographically. They need to decide what is most important to them. Is clinical practice what they enjoy most and if so in what environment? How much salary do they need to achieve their personal goals? Although increasing salary is attractive, the job that has the highest salary may not be the most personally rewarding. They have to think both short-term and long-term. I think it is hard to really know what you will want to do in 10 years but it is important for the fellows to think about what will sustain them over a long career in medicine and ultimately provide happiness and a sense of success. The long-term goals may require the fellow to be strategic in the first job such that the longer-term goals can ultimately also be achieved. Finally, GI fellows need to be realistic. There is no job that is 100% perfect and thus they ultimately should seek the job that is the best fit for their personal and professional goals.
RV: Career decisions are going to be made the same way they always have: where do you and your family want to live; what kind of people do you want to work with; how motivated are you to maximize income vs practice consultative GI; do you want an office practice or an in-patient practice; are you looking for advanced therapeutic endoscopy practice; what is the lifestyle of the doctors you will be joining; what is the on-call requirements; what is your short-term and long-term income; is the practice well managed; do you prefer to be an entrepreneur or focus on providing clinical care; are you risk averse. The priority that you place on issues like this, and your answer, will determine what your options are, and what the best choice might be.