2 Location

Abstract

The location in which we practice is a vital decision not only for the success of the practice but also for our own happiness and well-being. A variety of other factors play significant roles in this decision. Family preferences, proximity to training programs, population and demographic makeup, market saturation, and mobility are just some of the topics to consider when debating about where to practice. Your desired practice type (e.g., solo private vs. multispecialty group vs. academic, general dermatology vs. Mohs vs. dermatopathology) and job availability at each possible location also factor into this decision. This chapter will aim at reviewing all relevant topics regarding the location of your practice, including a rough chronology of the order in which these decisions should be made in order to set up yourself and your practice for long-term success.

The location in which you choose to practice is of vital significance, and one of the decisions you should be making early on, as you contemplate your future career. Before we begin our discussion, I would like to outline the structure of my thought process. I will be (admittedly, somewhat arbitrarily) referring to decisions regarding the placement of your practice as macro-level (e.g., in what region, state, city do I want to practice?) versus micro-level (e.g., what neighborhood, and typically medical vs. commercial/nonmedical real estate, etc.). As you would expect, most of the decisions you should be making early on in the process are macro-level, while those you make later will be more consistently micro-level.

Most would tell you that there are two main decisions to be made in concert with one another: what type of practice would I like to have (e.g., solo private, group private, academic, or multispecialty)? And what availability exists for this chosen practice type in my desired location?

These questions are certainly macro-level, practical queries you need to address as you plan your career. I would posit that another, more important macro-level question must be asked when first thinking about the location of your practice: What location will place me, as well as my immediate and extended family, in a setting where I will be emotionally and spiritually most secure outside of the office to better serve my patients and build a successful practice?

On its face, this seems illogical. Why think about spheres outside the office setting when deciding where to practice? The answer lies in my firm belief that the best version of me—as a physician, dermatologist, husband, father, son, etc.—exists in an environment where my whole self, not just my professional self, is satisfied. Furthermore, this best version of me is the greatest gift that I can give not only to my patients in practice, but also to my immediate and extended family and friends.

These coexisting versions of yourself are so obviously dependent on one another, and yet are so often overlooked. I see so many graduating residents and colleagues settling into jobs in locations not because they desired the location but rather because it was the best financial deal that was offered to them. While it may be the best monetary decision at the time (due to other common factors early in your career such as student loans, the costs of starting a family, etc.), these decisions are often short-sighted and contribute to early burnout and job turnover.

To successfully choose a location in which to practice, the first questions I believe anyone should ask himself or herself are as follows: Where do I want to live? What about my spouse, partner, or significant other? Are there any locations where they would be particularly happy or unhappy? If children are part of the equation, what is the day care availability and what are the school systems like in potential locations? What about the cost of living? What are the restaurants, public parks, and facilities available with regard to night life and outdoor activities? All of these are important questions that need to be answered when it comes to location.

Once these questions are answered, my guess is that 1 to 2 and perhaps as many as 4 to 5 locations will be considered as possible landing spots. Then, and only then, do I feel it best to evaluate another macro-level topic: What opportunities exist for your desired type of practice setting?

What type of practice do you feel most comfortable in: private solo practice, private group practice, multispecialty practice, or academics? Furthermore, what opportunities exist in relation to your selected practice type in the locations where you and your family would be satisfied? If you plan to go into solo private practice, you may be more inclined to look for a rural area or one that is underserved by dermatologists in order to ensure that your schedule is not empty starting out. If so, do you see yourself comfortable professionally being the sole decision maker for the practice immediately after finishing residency or fellowship with minimal input or assistance from partners or nearby colleagues? If not, perhaps a location where a group-practice setting exists may be more suitable. Conversely, if one chooses to practice in a seemingly saturated area, a multispecialty group, or perhaps academics, would prove to be a better choice. When tackling the notion of practice setting, be aware that many graduating residents begin their post-training careers by playing a hybrid-type role, engaging in part-time practice in a private or multispecialty setting and part-time practice in an academic setting.

If you are planning to start a solo private practice, another factor to consider that is intricately tied to location involves framing a business plan and securing a corporate loan. The use of a consulting firm can be particularly helpful in this circumstance. With regard to existing group practices, multispecialty groups, and academics, these concerns are not applicable. Hopefully, once these first couple of questions, family preference and practice setting, are answered, you would find yourself with 1 to 2 possible locations to begin your practice.

Another consideration when choosing the location of your practice is the proximity to the location of your residency or fellowship program. This is the point where two main macro-level decisions have been made, and most of the remaining decisions to be made fall under the micro-level category. This decision in particular is somewhat of a segue between the two. The reason that this is considered most important is because data shows that a majority of residents and fellows typically settle into practice within a limited radius from their training program.

This outcome is the result of a variety of factors. Residents are typically in their late 20s to early 30s upon completion of residency or fellowship, coinciding with a time at which many are getting married and/or having children. This family “anchor” can limit the mobility of a resident and his or her family in the immediate post-training phase and while seeking a job post-residency. In addition, information regarding available job opportunities near training programs is commonly disseminated among residents who may be interested and these positions are often filled quickly by local graduating residents and fellows.

This data point can lead a trainee in one of two directions. If the resident has matched into a training program in or near the location of his or her desired post-residency job opportunity, then he or she is quite likely to stay nearby if a good job offer presents itself. Conversely, if the resident matched into a program a considerable distance from his or her desired landing spot (e.g., the resident or his or her spouse wants to return to his or her hometown after traveling for training), then they are still more likely to settle within the radius of their training program than someone who trained elsewhere, but these various outlying factors may cause them to buck the trend and move back to their desired location in order to settle post-training if an offer is available there.

This becomes important from the perspective of collegiality and camaraderie. We can all agree that residencies often function like family units, with all the complexities and dynamics of interpersonal relationships in play between the trainees. Fellowships are akin to marriages, as the fellows spend countless hours working alongside their fellowship director. We less frequently take note of the fact that professional life immediately post-training can be lonely, especially in a solo private practice setting. Taking a position near the residency or fellowship program in which you trained, where co-trainees are also more likely to settle, sets one up for a future in which the relationships developed during training are more likely to continue into future careers, even if starting a solo private practice.

For many residents and fellows, particularly those who develop strong relationships with their colleagues in training, the possibility of continuing such a collaboration into future careers is enticing. While less likely, there are those who view their experiences with colleagues during the course of training as toxic, and for these individuals a change of scenery post-training is more than welcome. Regardless, an honest assessment of the relationships developed during residency or fellowship and the want to continue (or discontinue) them should be undertaken when thinking about where to locate your practice.

The population of the location (including all relevant suburbs) is another important factor to consider when examining potential locations for your practice. In 2015, the average clinically active per capita workforce in dermatology was 36 dermatologists per 1 million patients (which averages out to 1 dermatologist per 27,000–28,000 patients). ¹ This means that, ideally, the population of the location you choose would currently have less than 1 dermatologist per 27,000 patients. If the location in question has equal to or more than this per capita figure, it would suggest that the market is at or near saturation, as compared to the national average. This does not, however, mean that the location is necessarily a poor choice. If you offer a service currently not provided by the dermatologists at that location (e.g., you could be the only fellowship-trained Mohs surgeon or pediatric dermatologist), then a seemingly saturated market may, in fact, be a great site for your practice.

This segues into another factor to consider when looking at possible locations: the makeup of the current dermatology landscape in the area. You need to not only consider the number of board-certified dermatologists in the area, but also non-board-certifiedphysicians and midlevels who may be providing dermatologic care and would therefore prove to be possible competition for your practice. If you plan to start a practice with a bent toward cosmetics, consideration of medispas, laser centers, and similar sites also need to be factored in as potential competitors. When analyzing the current landscape in your possible practice locations, even if the market seems saturated, I would urge you each to determine if there is a particular niche within the market that you can fill. As an example, if multiple successful practices which incorporate cosmetics exist within a seemingly saturated market, it could turn out to be an ideal landing spot if you intend to practice complex medical dermatology, or vice versa.

For Mohs surgeons, much is dependent upon your ideal weekly case load, but a typical Mohs surgeon, on average, needs between 5 to 7 full-time practicing general dermatologists referring the majority of their Appropriate Use Criteria worthy cases to maintain a busy schedule.

The number of dermatologists in the area is not the only aspect that needs to be weighed when considering a location. I would argue that the demographic data regarding each of these possible competitors is just as important. How old are the existing dermatologists and their practices? If the practices employ midlevels, how many midlevel providers does each dermatologist oversee, and at how many locations? Is the supervising physician always on site or are the midlevels allowed to practice independently with only remote support and supervision? How loyal is their patient population? What is their reputation among patients in the community?

If you are looking to move into an area that seems saturated when looking at the number of dermatologists in a vacuum, but on further inspection realize that many of the providers in the area are later in their careers with loyal patient populations, then perhaps this is an ideal scenario to approach an older physician with a mature practice to gauge his or her interest in bringing you on as an employee physician with a potential for future ownership of their practice. If, however, many of the practices in a given area are young (< 3–5 years old), it would be a poor choice in which to locate another new practice. On the other hand, this is conceivably a scenario where the immaturity of the practices in existence may suggest a lack of patient loyalty and a possibility for growth of your own practice.

Similar demographic data on your potential patients is just as important. What is the average age of the patient in a given location? What is the average income level? What is the average level of education? What is the typical insurance coverage and/or payer mix? All of these factors may or may not be important to your particular practice structure but should nevertheless be considered when evaluating each possible location. If you are looking to start in a private practice setting with a cosmetic arm, it would be wise to choose a location where a sizeable portion of the population is over 35 years with a somewhat high education level and a mid- to-high income level, as these patients are more likely to possess the disposable income needed to support such a practice (with cosmetic procedures becoming more mainstream, however, these age and income figures may actually be skewing slightly lower). If, however, you are interested in academics or complex medical dermatology, the payer mix, income level, and education level of the patient become less important to a certain extent. Rather, you should consider a location with a large population, typically in an urban setting, and ideally, access to a large hospital system that will draw in such cases from the surrounding regions.

Market mobility is also important when assessing a potential location. Situating your practice in a convenient location for your patients will set you up for success. How far is the average patient you plan to serve willing to travel for the services you provide them? There are a number of ways to assess this. Average workplace commute in a given area is a good place to begin to evaluate how willing to travel patients within that area may be. Why, you may ask. Most patients when questioned would readily tell you that barring unusual circumstances, they would prefer services to be provided at a location that is close to either their home or their workplace, as these are the two locations in which the average patient spends the bulk of their time. This is human nature, which especially pertains to medical services: We would all prefer to have such services performed at a location in which we feel comfortable, and most people by nature are most comfortable in attending such sessions in the areas in which they spend the most time. As such, the locations of the home and workplace of your desired patient demographic, and their willingness to travel, become important in the placement of your practice.

Furthermore, does your particular desired patient demographic alter this average willingness to travel in any way? As an example, a Mohs surgeon’s expected patient demographic will likely limit expected market mobility. Think about it, would your grandmother choose to see a good Mohs surgeon who is located 5 minutes away or would she go visit the best surgeon in the state whose nearest location is over an hour away? My grandmother, and I expect most patients over the age of 65, would be more likely to visit a good surgeon who is 5 minutes away as opposed to an excellent one an hour′s drive further. In such a situation, you would perhaps be required to travel on a weekly basis to multiple locations in order to truly capture the market share in a particular area.

Conversely, if you are the only fellowship-trained dermatopathologist for 200 miles in every direction, or the only pediatric dermatologist specializing in rare genodermatoses, then you should expect the market mobility in your case to be increased, as you provide a service to the area not previously offered by any of your competitors.

Finally, as you consider all your options regarding the location of your practice, the final question I would urge you to answer is this: What is my long-term goal in establishing this practice at this location? You may not have an answer to this question at first. If so, that is acceptable because, at least, it will have you asking the right questions of yourself when you consider where to place your practice.

Is my goal just to test the waters and build some experience before moving on to another location? Perhaps I will be taking up a position that I assume to be temporary as I await a spouse or partner to finish his or her training, and so on. Are you joining a practice to perhaps be under the tutelage of a particular mentor, unknowing of whether or not you have a long-term future in that locale? Alternatively, are you planning to return to your hometown after a time away in training, and start and build a practice that will be yours until retirement?

These questions do not all require answers as you begin your search for a practice location. Nevertheless, asking these questions over the course of the process, as your search evolves, will aid you in finally settling down in a location that will set both you and your practice up for long-term success.

I wish you all the luck in the future and urge you each to believe in yourself and your abilities as board-certified dermatologists. We are all well-trained and capable to serve our patients on a daily basis. If our focus is consistently on the best patient care and evidence-based medical decision-making, then no changes in location, market saturation, new governmental regulations, invasion of outside corporate entities, etc. can stop us from what should be our primary focus: to always combine sound medical practice and exceptional patient/customer service in an environment that promotes the health and well-being of not only our patients but also ourselves. If we succeed in this goal, then we will be on the right path no matter our location.

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