Group, solo, private or employed: How to choose

The path for plastic surgery trainees is fairly prescribed: undergraduate, medical school, residency and, possibly, Fellowship. Long nights, hard work and dedication are required, but the main goal has always been clear. However, as they come to the end of many years of training, young plastic surgeons find themselves facing novel choices without knowing just how to go about making them – or understanding the short- and long-term ramifications of these choices. Additionally, after more than a decade of immersion in science and medicine, they've not yet developed the practical, non-medical skills that will aid them going forward: negotiating and reviewing contracts, writing a business plan, billing processes, running an office, etc. Hence, despite the joy of reaching the end of the training tunnel, the next step of a career in plastic surgery can be anxiety-provoking.

ASPS offers numerous symposia and webinars to help trainees address some of these gaps, but they tend to provide the "30,000-foot" view. In this two-part series, we seek to provide a ground-level look at the pros and cons of certain startup options by speaking with three plastic surgeons in private practice and in different geographic locations. Given their limited exposure to private practice models during training, our readers may glean important information from the responses to common questions posed to these plastic surgery veterans.

Panelists:

Dallas R. Buchanan, MD
Years in practice: 7
Practice location: Tampa Bay, Fla.
Practice model: Solo private; cosmetic and reconstructive (primarily breast)
Fellowship: None
Path to current practice
2014: Completed training
2014-18: Joined another plastic surgeon in Spokane, Wash.
2018: Started solo private practice in Tampa Bay

Troy Pittman, MD
Years in practice: 9
Practice location: Washington, D.C.
Practice model: Two-surgeon private; all aesthetic
Fellowship: Aesthetic and breast reconstruction
Path to current practice
2012: Completed training
2012-13: Faculty at John's Hopkins
2013-18: Faculty at Georgetown, director of breast reconstruction
2018: Private practice

Eric Payne, MD
Years in practice: 9
Practice location: Houston
Practice model: Solo private; craniofacial and aesthetic
Fellowship: Craniofacial surgery
Path to current practice
2012: Completed training
2012-14: Joined another plastic surgeon
2014: Solo private (shared office)

Who should consider a private practice?

Dr. Buchanan: For those who enjoy the extra challenge and details of running a business and desire an active and authoritative role over their career choices, the private practice model will provide more control.

Dr. Pittman: Those interested in creating their own brand and controlling patient experience – and have an entrepreneurial drive – will be a good fit in a solo or small-group private practice. A mentor once said: "When you pick up the pen in your office, do you want it to show your name, or do you not care? If the former, then private practice is for you." You'll need to tolerate the ups and downs of private practice. In the beginning, you may not book a surgery for two to three months and think that you're going to starve. That's when you'll need to ask yourself: How many starving plastic surgeons do you know? This is the time to market yourself by introducing yourself and your services to OB/GYN and dermatology practices. If you don't want to knock on doors, meet referring doctors and market yourself, then you may want to consider an employed model.

Dr. Payne: Those who should consider private practice are those who have the initiative to run their own business. They're also less interested in an academic setting, doing research and interacting with residents. However, they can still be involved with research and residency training in private practice. If you don't enjoy dealing with day-to-day business operations, then a private practice will not be enjoyable.

Who's better-suited to an employed model?

Dr. Buchanan: If you prefer a very structured, day-to-day practice and aren't interested in the administrative duties of practice management, you'll certainly be better off in an employed model. The big benefits of an employed model are:

• Lifestyle or work/life balance – You can prioritize your work/life balance much easier. You're responsible for being present at predictable times and can schedule your life appropriately.
• Predictability of income – You'll have a predictable salary and will never worry about the check clearing. You'll have compensation metrics, and those are clear. You can count on a consistent income from month to month or year to year. The downside is that the metrics for compensation can change at any time, and changes in reimbursement or renegotiation of the contract can lead to significant changes in your income.
• Focus on care – A large portion of the administrative duties are taken care of; you won't have to worry about such items as human resources, accounting, billing, overhead, etc. Most of the time, your only responsibilities will be patient care and documentation.

Dr. Pittman: If you're interested in areas of plastic surgery that require multidisciplinary teams (i.e., pediatric craniofacial surgery or gender affirmation surgery), an employed model may be of benefit because it's very hard to create those care teams in private practice. Additionally, for areas that require referrals (i.e., breast reconstruction or lower extremity reconstruction), being in private practice may become increasingly challenging, as more and more of these referring physicians are becoming employed and will thus refer to their in-house plastic surgery colleagues.

Dr. Payne: Plastic surgeons who are better fitted for an employed model are those who aren't interested in running the practice, as well as those who want to pursue an academic career. If you desire a private practice, especially a solo practice, you must be ready and willing to run a business.

How do you decide between solo private and group practice?

Dr. Buchanan: In the end, it will be about control. If you're OK giving up some control and stepping away from some the administration of the practice, then group practice is certainly going to be beneficial. However, you must keep in mind that if disagreements arise within a group practice, significant stress and work dissatisfaction can result – and may even lead to a provider leaving the practice and starting over in a new practice, which can be a significant career event. Disagreements eventually happen, and they're not always easy to resolve.

Dr. Pittman: Honestly, going into a solo private practice directly out of training is very difficult, due to the startup costs. There are several reasons that it's better to join someone who's senior: It allows you to be in private practice without having to run the business; it can provide a source of patients; and you can have experienced help with difficult cases or for a second opinion. You can learn how to run a practice – and if you choose, you can go out on your own after a couple of years.

Dr. Payne: People who go solo typically understand what it takes to set up the practice and are willing to learn how to run a business on their own. Ideally, you want to gather this information before you finish residency training. Those who don't have a desire to set up their own practice but still want to do private practice should join a group. This offers the opportunity to learn how to run a business from mentors or senior partners. Obviously, it's less work in a group private practice, because the day-to-day operations are shared among the group members. When I initially started my private practice, I partnered with someone who finished their Fellowship at the same time, and we benefited by sharing the workload and helping each other run the business. We also shared overhead expenses and on-call coverage. The other advantage is that we were equal partners in the business venture. One of the overlooked aspects of the partnership or group practice is having an exit strategy set up at the beginning of the partnership. This is like having a prenuptial for a marriage in the event one wants to leave or move away from the practice.

What's better for a solo private practice: Own your office from the start or office-share for the first few years?

Dr. Buchanan: It's a great idea to share office space for your own private practice early in your career. The concept of office sharing is basically an arrangement to split overhead costs while maintaining your own individual identity and business. I equate this to kind of a mini-partnership, as there will be some decisions about how to share equally and distribute costs. Especially if you're considering going into a very competitive and busy market in a metropolitan area, the cost of medical office space and overhead can be very significant for someone starting a practice. However, there will come a time where each practitioner will want to branch out and have their own office and unique identity, and hopefully this transition is peaceful and agreeable.

Dr. Pittman: The key to starting out is keeping your overhead expenses low. The three main expenses, in order, are: office space, staff and marketing. Time-sharing space and even sharing staff when you're first starting is a great way to minimize expenses.

Dr. Payne: Ideally, it's best to share an office to lower your overhead in the first few years of practice – and even after your practice matures. However, it can be difficult to find somebody who's willing to take on someone to share office space because they think of that other plastic surgeon as competition. In my opinion, this is the wrong attitude, because there can be synergistic competition when more than one plastic surgeon shares space in the same location – more foot traffic through the office ultimately benefits everyone in the practice. If two plastic surgeons set up offices near each other, their overhead isn't shared and patients tend to seek practices that are larger groups that offer more in the procedure niches they're looking for.

What are some advantages of solo private practice?

Dr. Buchanan: The substantial benefits are:

• Control – This is the major one. The solo private practice model gives you the ability to have total control of your future and allows you to make all decisions without having to clear them with someone else. If you want to control your own destiny and be responsible for the decisions that you make, then a private practice model suits your personality much better; you'll easily become frustrated within the employed model, where you have very little control over the decisions or the logic used in making these decisions.
• Income potential – Although compensation from an employed model can be very good, there's definitely a ceiling to your earning potential. Employed physicians are often compensated on metrics regarding their output and productivity; while his or her initial salary may be better than the initial salary for a private practice surgeon, over time the ability to grow in compensation in the employed model becomes limited, while the private practice model has much greater potential for growth over time.

Dr. Pittman: The obvious advantages in my mind are that you completely control how your practice looks and how it's branded, as well as its goals and values. You make all decisions and set everything up exactly how you like it. Another advantage is the sense of accomplishment from building something from scratch. You'll feel personal growth, as you'll need to learn things such as marketing and accounting to run your business. Similar to research in an academic job, developing and growing a business adds a different flavor to your life outside of patient care.

Dr. Payne: The advantage is that you ultimately make all the decisions for your practice. You can have a solo private practice with shared office space, which can reduce overhead. However, there still needs to be cooperative decision-making in some areas of the practice, and you'll likely need to accommodate another surgeon's time and use of the office.

What are some disadvantages of solo private practice?

Dr. Buchanan:

• Lifestyle or work/life balance – Within private practice, especially solo private practice, your work becomes the dominant force in your life. Although you aren't technically at work 24/7, you're usually thinking about work or doing something related to work almost all the time.
• Compensation – With a private practice model, your income can have significant variance from month-to-month and you can even have months where you don't get paid at all. This also comes with the price – probably the biggest disadvantage of a solo private practice – of everything within the practice falling to you. You are the de-facto office manager, CEO, CFO, H.R. manager and countless other roles, which means you must be knowledgeable about a lot of things and responsible for everything. This will demand a massive investment of energy and time. Hopefully, over time, you'll reap the benefits of this early investment in terms of financial security and job satisfaction later in your career.

Dr. Pittman: The biggest disadvantage is the unpredictability. You won't know how much you'll make; where your referrals will come from; and what you don't know. In addition, some of the advantages can be disadvantages. You have to make all of the decisions – including the marketing and direction of your practice, when you haven't necessarily been formally taught those skills. It can be scary at times and you need the stomach to get through it.

Dr. Payne: The disadvantages are that you have few people to help you run the day-to-day operations. You'll also miss the ability to help each other on difficult cases, such as asking for advice or even getting surgical assistance in the O.R.

What are advantages of a group practice?

Dr. Buchanan: Mainly, the benefit of splitting costs and overhead. As a surgeon, I'm traditionally away from my office about half of the time doing surgery, and if no other passive revenue streams flow during this time, I'm essentially paying for staff, rent and other overhead costs when I'm not using my office. If you're in a group practice, you can be much more efficient with the use of resources and cost-containment strategies.

The major advantages of this practice have to do with the ability to offload or distribute certain parts of the business, such as practice management, overhead cost-sharing and a multitude of other things – such as increased negotiating power as a group, better ability to compete in the marketplace, etc. You'll likely be able to hand off to your partners certain parts of the practice that you don't like and take on other things that they may be better suited to deal with.

Dr. Pittman: As I'd mentioned, joining a group practice shields you from having to worry about the business side while you get used to being a new attending. Another advantage could be decreased frequency of being on call, though this can be a negative if you're trying to get busy. You're also likely to have some guaranteed salary. Finally, a group practice may be able to feed you the cases you need for board collection – which can be hard to get in a solo practice.

Dr. Payne: The opposite of solo private practice disadvantages are the group practice advantages.

What are some disadvantages of a group practice model?

Dr. Buchanan: Giving up control. A group practice with one other provider will have a 50-50 split on every decision – who to hire and fire, the equipment or supplies to buy or how to proceed with the future of the practice. Unanimous decisions will be needed before anything gets done. If in a larger practice of 30 or more physicians, it'll likely be "majority rule" for these decisions, and if you disagree with certain things in the practice, you may lose control over that decision-making.

You might find that certain decisions that you feel very strongly about may go against your preference. These can involve the direction of the practice or of your individual patients. If another partner in your practice focuses on facial cosmetic surgery, for example, and you're practicing general plastic surgery, your group may decide to filter all the facial cosmetic surgery to that provider rather than to you – and if this isn't the direction you see your practice growing, significant issues may arise over time. If problems force you to leave that practice, sometimes there isn't much left to show for what you've put into it. In a solo practice, there's never any concern about control or having to abandon what you've put effort into.

Dr. Pittman: You need to be realistic about your goals. Statistically, 80 percent of people leave their first job. You need to look at the practice you're joining and ask yourself: Who's running the practice; how is it branded; what is its practice volume? The answers will give you an idea of how successful you can be there. If the practice's brand is the other surgeon's name, how will you be able to market yourself? If the other surgeon's spouse is the practice manager, how fair will be the staff sharing, cost sharing – and, even, how the phone is answered for your patients? One way to tease this out would be to ask if the surgeon or group has ever had an associate, and if not, why they feel this is the right time for them to bring someone in. Even asking these questions is not foolproof in preventing you from entering a bad relationship. That's why it's important for you to have an exit strategy and an iron-clad contract (reviewed by a contract lawyer) before joining.

Dr. Payne: Some of the disadvantages include having to compromise or losing autonomy in decision-making. Sometimes that can come with hiring and firing certain office personnel. If the senior partner insists on hiring their spouse as the office manager, it can be very difficult to build a collegial working environment. Ideally, everyone needs to be treated fairly and respected.

Should one consider an employed position and later transition to private practice – or begin private?

Dr. Buchanan: This decision will likely come down to a financial question. If you know you want to have a private practice after leaving training but aren't in a financial position to invest significantly in its startup, you may not have that option. However, if your ultimate goal is a private practice and you have sources of financial security that allow you to start right after training, I don't see much downside in this – you can start investing in yourself early-on and not have to worry about wasting time or effort in an employed model. This was my case: I went into a blended employed/group practice model for four years before I could start my own private practice. But looking back on it, I wish I would've made that transition sooner, rather than spend four years in something that I couldn't "take with me" when I left.

Dr. Payne: Several plastic surgeons consider this option of being employed for one or two years before starting their own solo private practice to build up equity to start that practice. There are advantages and disadvantages to this strategy. The first advantage is: You won't go into significant debt and can begin to build your nest egg for retirement. The downside: The patients you treat during the employed position aren't truly your patients – they're part of the system that employs you, and you may not be able to continue treating those patients in the future. You also may lose your before-and-after photos, unless it's agreed that you can keep those for marketing. Another disadvantage to being employed for several years is that you essentially start over again with your private practice. Every person who begins practice after residency will experience a significant slowdown in the number of surgical procedures performed and patients seen in clinic. The best analogy is that during residency, you feel like you're driving 90 mph down the freeway – then you begin your career as an attending, but somebody shifts you into first gear and you can't go faster than 15 mph. Now imagine if that happened twice when you started your solo private practice.

How can young plastic surgeons become known in the community?

Dr. Buchanan: This has a lot to do with the type of practice you want to start, and the market in which you're starting. Traditionally, getting on E.R. call schedules was a good way to begin and grow a private practice. However, with a few possible exceptions, I'm not so sure that this is a great strategy anymore when it comes to plastic surgery. It all depends on the type of practice you're trying to build. For a busy reconstructive practice, relying on referrals from other providers in the area, getting privileges at a hospital and taking call can, hopefully, fortify your referral streams. However, with reimbursements for reconstructive work rapidly declining year-to-year, it's going to be very difficult for you to maintain a private practice on reconstructive work alone – especially if you're a solo provider in an area with poor reimbursement or significant competition. Some of my colleagues practice in areas where E.R. call can be a lucrative prospect via reimbursement, but this isn't the case in my market. If you're trying to start a practice that relies on referrals but can't get on call schedules, there are certainly alternate ways to introduce yourself to the referral providers you've targeted to help grow your practice. However, if you're looking to build a cosmetic or elective plastic surgery practice, most of your referrals will come from direct consumer marketing and/or word of mouth advertising and patient referrals. Therefore, participating in E.R. call schedules and meeting other physicians in the area won't contribute as much to your practice growth as will your marketing strategy.

Dr. Pittman: The most conventional way is to take as much E.R. call as you can. You can take hand call, facial trauma call and general practice call. Hospitals will often pay for call coverage, so that can be a small source of revenue when you're first starting. Taking call is also a great way to get a potpourri of cases during board collection. Other things you can do are wound care, injectables and other office-based procedures.

Dr. Payne: In terms of taking E.R. call, some surgeons who've been taking call for a number of years may be ready to scale that back. Even if the call schedule looks full, I recommend asking the hospital administration if there's a way you can help out in the future. There are also a number of hospitals that don't have plastic surgeons on a regular call schedule. This is an opportunity for you to meet those emergency medicine colleagues and provide them your contact information – so they can call you with any future consultations. You need to be very specific with them about what you will and will not see for consultations. Typically, in the beginning, you want to be the person who always says "yes," if you want to grow your practice quickly.

Another way to get your name out is to meet with referring providers. This can involve meeting with family medicine and internal medicine doctors to let them know you can help with breast reductions or any other breast reconstruction cases. If you're interested in pediatrics, meet with pediatricians and let them know you're available to assist them. In my practice, I treat craniofacial and pediatric plastic surgery, and I have a large following of private pediatricians who continue to refer patients to my practice. Plastic surgeons interested in trauma or hand surgery should reach out to E.R. physicians as well as primary care physicians to build their practice.

How early should one start preparing for private practice?

Dr. Buchanan: I think the old adage is true: It's never too early to start preparing. Just when you think you have everything planned, you'll come to learn that there are a multitude of things for which you didn't plan. If you have a timeline in place for opening a private practice, start planning for its grand opening at least a year in advance.

Dr. Payne: Planning for a future practice should begin in the first year of residency, whether it's private practice or academics. There are number of ways to do this:

• Create preference cards for each surgical procedure
• Create pre-op and post-op instructions for each surgical procedure
• Create template operative notes for each surgical procedure
• Create website content for each surgical procedure, in your wording – don't plagiarize other surgeon's websites
• Create a business plan

What can you do in training to help the transition into private practice?

Dr. Buchanan: It's a difficult time to start working on a transition into private practice or starting your own business. You're working a ton of hours and have a long list of responsibilities, but very little free time. Your ability to plan a private practice will be significantly limited. However, one of the biggest resources that we don't utilize during our training is our teachers and colleagues. Many of the connections you've made during training are either currently in private practice or have had experience in the private practice world and are a wealth of information and knowledge. I'd suggest that anyone considering moving directly from training into their own private practice make a concerted effort to "pick the brains" of the connections they've made and have them help with that planning. One can often avoid future pitfalls by talking to those who've fallen into those pits before.

Dr. Pittman: If you're sure you want an aesthetic practice, talk to as many private-practice aesthetic plastic surgeons as you can during training, and educate yourself on how to start and build that practice. I also recommend learning how to write a business plan – you'll need to present a business plan to a bank in order to get funding to start your practice. Also, if you're planning on staying in the area you're training, get to know the local implant, neurotoxin and filler reps. They can be a huge help when you're starting out. Most importantly, you'll need to learn about marketing. For that, I'd recommend reading Building a Story Brand by Donald Miller. You'll also need to familiarize yourself with social media platforms.

Dr. Payne: Read The Business of Plastic Surgery: Navigating a Successful Career by ASPS members Heather Furnas, MD, and Joshua Korman, MD.

Dr. Parikh is PGY-6 at Houston Methodist Hospital.