Making the practice switch: One doctor became an employee, the other started his own office

Physicians often say: They love their work, just not their practice environment.

The exodus is largely from solo or small practice to large-practice or employed situations, according to surveys such as one released late last year by the Center for Studying Health System Change. Doctors cite long hours spent pushing through towers of paperwork and working for smaller and smaller reimbursements, with less quality time left for patients and even the physicians' own families.

But it's not all one-way. Physicians tired of what they see as the politics and stifling lack of clinical freedom in a large-group or as an employee are breaking away into solo practice or a small group. They argue that the ability to set your own schedule and work under your own terms can allow for more quality time with patients -- and the physicians' own families.

Here are personal stories from two physicians who changed their practice environments.

Internist Timothy Gatewood, MD, left a small private practice in Kokomo, Ind., to become an employed physician for Howard Regional Health, the local hospital system. Robert Jones, MD, a Raleigh, N.C., orthopedist, left an employed position at a large group to open a new practice with two other partners.

Physicians who see themselves in these stories can take some instruction from these experiences, experts say. However, it is crucial for physicians to consider their own motives for changing their practice settings, whether their personality would best fit in an employed or small-practice setting, and whether they -- and their families -- are ready for what can be an arduous adjustment.

In their own words, Dr. Jones and Dr. Gatewood talk about why they did what they did, why they were happy to do it, and how it all came together.

Robert Jones, MD -- From employed to small practice

"I'm embracing the move to private practice. I will have better control over my employees' morale and my expenses, and a better pulse on the practice. I will have more quality time with my family.

"I started in a small office, with three physicians. It grew to five physicians, then the office was bought out by a large group. That's when I decided to leave. I feel strongly that for both patient care and efficiency and function of the practice, that a small group is a better fit.

"I see this as a great opportunity, a challenge. At this stage of my career, it is much more conducive to my lifestyle. Unlike when I was an employed physician, I will be able to take little or no emergency calls; they can go to younger physicians. I can manage a small, efficient staff. I can control when we open and close. And I can decide how expensive the furniture in my lobby will be. There will be no paranoia to expand to compete with larger groups.

"More importantly, I can spend more time with my kids. If I was to open a solo practice, I couldn't do this, but I am working with other physicians. We will cover for each other and work alternate weekends. In my previous practice, the work load was dictated by senior management. You might not be able to take Friday afternoons off, for instance.

"I had all this figured out before deciding to go private.

"Once I decided I wanted to move on my own, I sat down with a former senior partner to talk about the pros and cons of private practice. I also spoke with a consultant and orthopods in other parts of the country who made the switch. There were few negative comments.

"I would not have been able to put this together without the help of the former partner, consultant and other orthopods. They told me what mistakes they made, what they would have spent more money on, and where they would have spent less money. They told me the importance of having the right personnel.

"I'm taking about a year off between leaving my other group and opening my own office. It's been absolutely beneficial, and an invaluable tool if you can afford it. I've spent the time traveling with my family, working with consultants and doing consultant work. I'm interviewing people, seeing architects and real estate brokers, talking to different hospitals.

"From a practice management view, I don't think it's hurt to not have practiced for one year. From a lifestyle standpoint, it's been critical. It's like taking a sabbatical in my mid-40s.

"The most frustrating part so far has probably been picking the perfect location. I was looking for a place with close proximity to home and several hospital systems with which I wanted to be aligned. Most of the real estate offerings did not have what I wanted. Then I had to work with an architect. I had my own ideas on design, but the architect knew about laws I needed to abide by.

"The biggest problems I encountered were ones I had no control over -- getting permits from the city in a timely manner, discovering the heating and air conditioning unit needed to be replaced. It set us back eight weeks. But you need to take setbacks in stride. I saw the extra eight weeks as more time to train for a marathon.

"I will have two partners, and there's a need for boutique sports medicine in Raleigh. I'm not worried."

Timothy Gatewood, MD -- From small practice to employed

"I never envisioned being a boss when I was in medical school. I didn't think about looking at spreadsheets or worrying about insurance and employee compensation. I wanted a structure that would focus on patients, and with my practice, I had a business that was very complicated. Especially for a primary care physician, the paperwork is complex and the billing system is a real challenge. I don't apologize for not being interested in that side of practice.

"I left my practice about a month ago to join Howard Regional Health, which is also in Kokomo. I was one of several partners in my practice, which I joined 10 years ago. We had about 20 employees.

"It was a difficult decision. I never thought I'd give up medical practice. I love practicing medicine. I love internal medicine. I love taking care of patients. It was the business side that I didn't feel I was called to do. If someone else could do it better, fine. It's a fair exchange.

"I made the move to being an employed physician with an eye on the future. I have young kids at home whom I want to spend more time with, and I don't see the business side of medicine getting any simpler.

"When I left the private group, I told my patients there are only so many hours in the day and the complexities of being involved in a business required more hours than I wanted to spend on the business portion. I wanted to simplify my life and focus on taking care of patients.

"It was a painful decision. I spent about a year debating the pros and cons. But it helped that I had understanding partners.

"We had many discussions about the future. It just got to the point that it wasn't right for me. We are still colleagues. We continue to cover for each other on weekends and nights. I worked closely with them for 10 years and hold them in high regard.

"The move was easy. There were no legal problems, no problems with my former partners.

"I don't regret my decision. I did not find it difficult to go from being a boss to an employee. But I believe it depends on who is doing the employing. In my case, I basically moved my practice across the parking lot. The scope of my practice has not changed. I still do 80% to 90% of my work on an outpatient basis.

"And I know the hospital administration at Howard. I know other physicians employed by them. I trust they will allow me to take care of patients the way I want. If that stops being the case, then I will stop working for them. If they micromanage how I take care of patients, I could not work for them.

"I would hate to give another physician advice. It's a personal decision. Every physician needs to do their own calculations of the pros and cons of being responsible for everything versus simplifying their life. It's a trade-off. They have to focus on what they're good at. If running a business is one of the things you're good at, go for it.

"But remember, the days of a physician hanging out a shingle and taking care of a few patients a day are gone. You need billers, coders, multiple fax machines, etc. There are so many facets, and it's not getting simpler.

"No one knows what the future holds. It is an uncertain time for everyone."