Key points

Introduction

The perfect job is rarely available as a first job, but finding a near perfect job is possible. The process can be arduous, yet very exciting, as your formal training is concluding. It is vital to identify the important aspects of a career and how that fits into your life as a whole. This begins with self-evaluation and reflection. What is important to you in a job or career? This is one of the first steps in understanding how to evaluate various job offerings from a macro perspective. Frequently, location, practice type, family proximity, and salary are among the most important aspects of choosing a specific career with orthopedic surgery being no different. When considering any job, you will have to determine what are the most important variables. Is it location? Is it practice type? Is it salary and earning potential? Are there other variables such as no call or passive income opportunities that are essential to your career plan? It may be impossible to find a job that fits every single requirement, but stratifying the importance of these will provide a framework by which to begin the process.

Why Private Practice?

What draws you toward the private practice model? According to the 2018 AAOS census data, 57.2% of practitioners entering the work force were in some form of private practice model ( Fig. 1 ). Orthopedic group private practice comprised 65% while multispecialty and solo practices made up 20% and 15% of the model, respectively. The last two are roughly equivalent to those in academic practice (18% total). The benefits of private practice are vast, but autonomy tends to be a common reason for entering into the model. Having the say over your own schedule, while controlling the volume and types of patients you would like to treat is a decision you will get to make. You can take vacation without approval or time limitations and plan your work schedule to fit your personal needs.

Orthopedic practice setting.

These benefits come with drawbacks which will be addressed in more detail in other sections but some, if not all, of the administrative burden will fall to you. It is important to understand the rules and regulations affirmed by medical governing bodies and ensure that you stay within the required parameters set forth. These can be ever changing and will always affect how the medical and business aspects of your practice are managed.

All variables associated with a job can be defined in several ways and rarely can you find a job that checks every box. There may be variables that are not considered at the time you sign your first contract, but by educating yourself you can have as complete a picture as possible.

In a study by Laratta and colleagues, nearly 50%-70% of orthopedic surgeons change jobs within the first 5 years of practice. They found that changes were due to financial reasons in 34% of practitioners while 31% cited the practice not being as advertised. This, in general, is very telling and may point to the lack of business education and mentorship provided during residency and fellowship training.

How Do I Begin Looking?

It is never too early to begin looking for a job. In fact, the earlier the better as it affords greater control over variables for where you will start your career. Unless you worked in a different role or industry prior to attending medical school and beginning residency, it is unlikely that you have gone through the evaluation process when looking at career opportunities. While the decisions to be made regarding what you would like in a job are numerous, identifying basic prerequisites for your job will help narrow down the search process.

Many variables play a role as to why orthopedic surgeons are changing jobs, most frequently within the first 5 years of practice. Mitigating and controlling variables such as location and practice type are necessary from the very beginning of searching for your first job as an attending surgeon. If you want to be in the southeast or pacific northwest, it does not make sense to entertain jobs located on the other side of the country. If you cannot tolerate long winters or humid summers, considering a job in these specific climates is not time well spent.

It is usually best to lean on your mentors early on. It is recommended to ask them about potential job offerings as orthopedics can be a small network. Ask them about evaluating potential jobs and what they recommend looking for in a career. The more advice you seek the more objectively a job can be evaluated. However, besides sorting through all the advice, this does require you to do some self-reflection as described at the beginning of the article. If you do not know what you want from the get-go, it is hard to find potential jobs that may fit your ideal scenario. Ideally, you do not want to squander your limited free time evaluating practices in which you have no interest.

Job listings are frequently posted online through formal orthopedic channels. Networking can often link you to finding a niche that you can fill based on your skillset and training. There are even known successes with cold calling practices to ascertain specific needs. However, if these fail or are not as fruitful as desired, using a recruiting service to help identify job opportunities may be necessary. Regardless of your approach, always try and understand why a vacancy is present or a specific job has not been filled already. Understanding why an agency was hired to help fill that position can be telling. If you can speak with an orthopedic surgeon of a practice who has since left that position, you can glean a tremendous wealth of information. You may find they left due to issues with the practice itself, partner arrangements, practice climate, case and patient volume, or for personal reasons. Any information will provide insight on how the practice functions and help you understand more about the position that may not otherwise be available.

Self-evaluation

The adage “you don’t know what you don’t know” rings true when you become the sole decision maker for patients’ treatment plans. You will learn a myriad of information about patient care and pathology in your training, but you likely will not use all of it in practice. “The eyes cannot see what the mind does not know” is also important because you need to recognize when certain pathologies, especially those with high mortality, are in front of you.

Understanding your strengths is part of how you will tailor your practice and the type of job you will want to pursue. Joining a group that has seven other providers that perform your niche procedure may make it more difficult to establish a practice and referral pattern. To evaluate this, practice administrators or coders should be able to provide a list of Current Procedural Terminology (CPT) codes billed over the last few years for your practice. This can provide insight into what types of patients the practice is evaluating and treating. Moreover, it will demonstrate the types of cases being performed and what is being cared for while taking call. Is there a lot of fracture care or wound care performed? Are long bone fractures being treated or referred to tertiary centers? Critically evaluating billed CPT codes will clarify volume. If there are a low number of specific cases that are performed, could you market yourself and establish a referral pattern to increase that volume?

Understanding your weaknesses may be even more important. Knowing what your group offers affords you the ability to refer to your partners, which can build strong relationships. Realizing and respecting your abilities will help provide excellent patient care and keep you from unnecessarily taking surgical risks that are outside of your skillset.

Potential Job Evaluation

Many requirements of your job cannot be fully evaluated prior to signing a legally binding contract. Thorough and complete evaluation of a practice is rarely feasible. There will be unknowns and there will be drawbacks. Homing in on a job which the pros are huge and the cons are tolerable is important. One thing to identify before signing on the dotted line is the transparency of a practice, especially the finances.

Transparency can be very telling about how the practice functions. If the practice is willing to provide monthly profit and loss statements showing collections, revenue, and expenditures for the practice and each partner, it can be telling about how that practice functions from a business standpoint. Quite the opposite can be true as well if the finances are difficult to understand or not clearly laid out. Probing into explanations for why a practice handles finances and decision making should be done tactfully and in a respectful manner. While this is only a sliver of the evaluation process, many red flags may be raised in the setting of confusing and convoluted bookkeeping.

Practice Setups

This issue can be difficult to spot when interviewing and evaluating different jobs. Oftentimes, it is impossible to know the overall structure of a practice initially. Trying to delineate how the hierarchy of a practice is set up is very important. If a partnership track is offered, how is your candidacy evaluated and determined at the time of being made partner? Is there a substantial financial burden associated with becoming a partner in a practice. Moreover, if there is a financial component, what does this money go toward? Are you having to pay, or buyout, older partners who are on the verge of retirement? Additionally, what are the benefits of becoming a partner of the practice? Do passive income opportunities await once becoming a partner with the practice? Regardless of the arrangement of partnership, you will want to understand what partnership means for you.

Practice Environment

Outside of the practice itself, understanding your practice environment will help you determine how you are going to build your future practice. Appreciating neighboring competitors’ services and those within your partnership are important. Are you bringing a new distinct need to an area that is underserved or do you perform a specific set of procedures which are not offered currently in the local market? Do you fill a niche that is unmet in the area? These can be important when trying to understand what other services are offered around the area where you will establish your practice. These are also excellent ways to market yourself to the local community.

Establishing yourself within your community requires a lot of work. Rarely will you enter a practice that mirrors those with whom you trained. Their practices have taken years to establish and are often associated with academic programs. In these settings, a large number of surgeons with more specific skillsets to address higher acuity issues with internal referral occurring is common. Understanding that you likely will not have a tailored practice matching your residency and fellowship training right out of the gate can help temper your expectations. With this, it is important you seek out the opportunities to stay up to date on techniques outside of your focus should you choose further subspecialization as general orthopedic medicine will be important as you build and sculpt your practice over the years.

Patients

In a private practice setting, the referral arrangement is less developed than academic medicine where a well-established, internal referral system already exists. When commencing your private practice career, it is important to discern where your patients come from. This is often a combination of marketing, direct referrals from patients, taking call, primary care networks, and online research or reviews. The percentage of patients from these different categories will vary throughout your career but tend to rely heavily on call and marketing at the beginning. You may consider yourself the best trained surgeon in the world, but if the community does not know you exist, you will find your schedule light, if not empty.

Before your first day of practice, you need to understand how you will be marketed by the practice. With only so much time in a day, you cannot visit every local primary care physician, physical therapy practice, and nursing home on your own unless these practices and services are limited due to the need of the population. Smaller communities will likely have fewer medical services due to the smaller population. While these are all useful activities to help establish referral patterns by putting a face with a name, it is time-consuming. I personally believe it is very helpful in getting your foot in the door with providers but changing their referral patterns can be a very difficult task. If you are partly contracted with a hospital who may be supporting your guarantee, they often have a physician liaison that works with the local practices to establish relationships. Having them act as an intermediary who can introduce you to local providers, referral coordinators, and office staff can help establish rapport given they are often well known in the community.

Most importantly, providing compassionate, thorough care is often what is remembered by patients, which can lead to your patients becoming your best referral source. Knowing one of your patients referred their family member to you speaks volumes about how you treated that individual. The practice of being available to patients and communicating effectively will often pay dividends. You should strive to promote your confidence through humility. It is not an infrequent complaint of patients that they are seeking another opinion from another surgeon due to the prior surgeon’s bedside manner or lack thereof.

Contracts and the Art of Negotiation

The legalities associated with your job are best handled by a trained professional well versed in the legal language contracts utilize. There can be many pitfalls and rigid language contained within legal documents which may directly affect your job. Deciding if you will have a healthcare specific contract attorney review your job offer is highly recommended unless you fully understand what your contract is clearly stating. Your contract attorney usually charges an hourly rate to review, negotiate, and work on your behalf. With the right attorney, it is money well spent to avoid the legal issues that can arise if your plans change prematurely.

Amongst the flowery verbiage, the contract will often include your compensation, the term length of the agreement, liabilities, paid time off, and noncompete restrictions. These variables can frequently be negotiated, but if you do not understand the offer, you will have a difficult time negotiating on your behalf. Additionally, many physicians may not be able to effectively negotiate on their own behalf. You may be surprised at the flexibility of groups in terms of total compensation, especially with a competing formal offer. Outside of narrowing a noncompete radius and higher salary, negotiating for more paid time off, broader maternity or paternity benefits, support staff stipends, sign on bonus, student loan reimbursement, relocation stipends, or modified work schedule can all increase your bottom line. Ensuring you stay within reason while negotiating is important but usually the worst thing you will hear regarding your requests is “no.”

The Business of Medicine

Once the prospective job has been fully evaluated and the formal contract has been signed, the business side of medicine will become even more apparent.

William Osler is quoted saying, “the practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Medicine is multifaceted and ever changing. Over the last 100 years, medicine has embraced advancement in technology and innovation improving the care for our patients. However, for those entering a private practice setting, often more so than their academic colleagues, understanding the intricacies of running a business are paramount.

The business aspect of medicine is also rarely taught in training. Nearly 90% of trainees feel unprepared for the business of medicine. Occasionally, some programs have a brief focus on the business of medicine, but the majority of training is solely focused on medical care. The business aspects of medicine are rarely a focus during training. Of those surveyed, 85% had minimal to no business education during their training. This is concerning when it pertains to the number of orthopedic surgeons enter private practice who are changing jobs within the first 5 years. The question remains – would changing jobs within the first 5 years decrease if there was a greater emphasis on the business of medicine given a large portion of trainees are entering into private practice? A more in-depth analysis of programs that have a business focus as part of the training curriculum compared to those that do not may provide greater insight.

Autonomy and Decision Making

Private practice is often very appealing to orthopedic surgeons as they tend to be self-motivated, driven, and very hard-working. There is a level of autonomy that affords a lot of control over day-to-day occurrences within your clinic. All work and no play is a possibility for someone who finds their hobby identical to their career, but this is rarely the case. When you are in control of your own schedule you can block clinic or limit the number of procedures to permit activities outside of work. However, in the setting of private practice and outside of any guaranteed income, not working and not billing means not getting paid for your time. Only you can decide how important extracurricular activities are to the balance of your desired career. This is only one of many decisions that will affect your practice.

Even before day one in private practice, you will become a primary decision maker. The extent of these is governed by your practice set up and hierarchy but in general a multitude of decisions will have to be made which will affect the daily operations of your practice. Who you choose to hire to work directly with you on a daily basis has a huge effect on your business. Having a surgical coordinator or nurse who is unpleasant with patients and short when responding to their requests is a recipe for disaster. It will leave patients upset and alienated. In orthopedic surgery, there are frequently other providers with a similar skillset who are happy to care for “your” patient. Evolving your practice is imperative to success. It is important to realize that decisions affecting a practice can be continuously modified to improve efficiency and minimize waste. Hiring and firing, as addressed in a later section, is a difficult and occasionally uncomfortable process, but being passive and having staff affect your business will be significantly more costly in the long run.

Overhead

Overhead is a dreaded but essential topic to running a business. Understanding how your money is being spent prior to paying yourself is a requirement for running a successful business. Given a majority will be joining a private practice that is already up and functioning, understanding the line items within the profit and loss (P&L) statement as clearly as possible is an essential yet daunting task. Comprehending how revenue is spent prior to paying yourself will guide you in striking a balance in your practice.

Moreover, there are expenditures which can make your life significantly easier, but the cost comes out of your own pocket. Utilizing an advanced practice provider (APP), scribe, specific electronic medical record functions, and on-site billing can be beneficial. Billing and coding, which is a vast topic outside the scope of this manuscript, is a vitally important skill and quite foreign to most orthopedic trainees. However, throughout your career, there will be countless opportunities for on-the-job training. Basic comprehension can limit mistakes but some lessons will be more expensive or painful than others so the more you understand prior to starting the better.

While individual overhead is tied directly to you as a practitioner there is often shared overhead as partners of a business will frequently share a common clinical space and staff. More specifically, shared overhead is often split in different ways in practice: fixed, collections percentage, or a combination of the two. This will often vary based on the number of partners that you have in your practice and how busy the practitioners are clinically. If only certain practitioners provide specific injections such as hyaluronic acid, these costs may be directly tied to that provider’s P&L, so the cost is not shared across the practice as a whole which is more common in a multispecialty private practice setting. This may also be the case if the volume widely varies between partners within a practice.

All things considered, the goal for overhead is the same – keep it as low as possible. Needlessly wasting revenue on aspects that do not progress your clinical practice forward should be limited and deserves scrutiny. Nevertheless, running a practice is an expensive business as staff wages and material prices climb. Pay close attention to the percentage of your revenue directed toward overhead to ensure your business remains solvent.

Pay

The discussion of money seems to be a taboo subject in a lot of situations but given this will be your livelihood it is imperative to understand how you get paid. Directly out of training many physicians will find themselves utilizing a guaranteed salary for 1 to 2 years, which can frequently be negotiated. During that time, you will want to build your practice and establish yourself within the community. When you are no longer on a guaranteed salary will you be getting paid from collections or relative value units (RVU). Collections tends to be the primary method which is a convoluted system where an agreement between you and a third-party payer has been made regarding how much will be reimbursed based upon a service provided. More simply put, you “eat what you kill.” The caveat (one of many) is that a third party will often dictate how much will be reimbursed, if at all, for a certain procedure based upon the level of service and procedural code (CPT) provided so sometimes the kill is not edible at all. Understanding this within your practice is vital to continued viability and success.

Insurance participation will be a primary focus from the beginning and yet another decision that will have to be made. Determining what types of insurance you will accept and contract with will determine the number of patients you may see. This will include commercial, government, worker’s compensation, and self-pay. At the most basic level, the acceptance of more insurance plans will increase the number within the patient pool that can have you be their provider. Another consideration is that if you take call you will have significantly less control over your patient and their insurance status. If you only accept a limited number of commercial insurance providers you may find that your weekend call caring for a displaced femoral neck fracture will be written off if you do not accept any government insurance. The caveat to this is that many insurance companies have emergency services clauses which you can bill without contracting for office visits and elective procedures. Individuals may find that certain insurance companies or contracts are simply not worth excepting for a myriad of reasons from reimbursement rates, prior authorization requirements, or simply reimbursing in a timely fashion for services rendered.

Active Versus Passive Income Opportunities

Outside of getting paid based on your collections, which is most of your active income, there may be passive income opportunities available, especially after partnership. This often is related to owning a physical therapy group, imaging center, or ambulatory surgery center (ASC). Real estate options may be available based on where your clinic is located and who owns the building from which you lease clinical space. Additional options include expert witness and chart review which is paid at an agreed hourly rate.

Passive income can often bolster your yearly earnings but may require significant upfront cost. Partnering in an imaging center or ambulatory surgery center can be expensive ventures but may end up paying lucrative dividends in the long-term. These decisions are often made based on an individual’s financial situation and best discussed with someone well versed in the space as the contracts can be rigid and even parasitic.

Consulting in various forms including working locums tenens jobs can be additive if necessary. Usually these require working in an underserved area as the idea is to fill a need or void where orthopedic coverage is not readily available. The return for this is often an increased hourly rate or an agreed upon stipend for the time spent serving this area.

Administrative Requirements

In private practice settings, administrative responsibilities will be a part of the job. Hiring an office manager with experience in the field will alleviate, but not eliminate, the exposure to many tasks. They may also be able to manage the practice to ensure all guidelines and governing body requirements are adhered to appropriately. Beyond decisions affecting the clinic directly you will become responsible for decisions related to staffing. Hiring and firing is never an easy process. It is one that can be time consuming, but it is essential to running and maintaining an efficient clinic. Given the process can be onerous and staffing difficulties that may be present in your practice area can lead to passively sticking with staff who may not have the same goals as you for your clinic. You want to surround yourself with those who have a desire to match your expectations as they will help your day be efficient and grow your practice.

Work-life or Life-work Balance?

I prefer the term life-work balance as work is very fulfilling but remains one facet of my life. Private practice can afford an excellent life-work balance but that does not mean it is straightforward or simple. Planning in advance is key to maintaining this balance. There will be a number of unforeseen issues that arise from personal to administrative to clinical. These are risks that cannot be controlled. While taking call provides one of the greatest exposures to uncertainty, the timeframe of call is well defined and will develop your relationships with the community and colleagues.

Everyone’s life outside of work is widely variable. Whether you are single, married, divorced, have a family, planning to have a family or not, will play a role in how you structure your business. Determining a life-work balance is crucial to a successful and fulfilling career, but this too, is extremely individualized. Hiring a physician assistant, nurse practitioner, athletic trainer, scribe, and/or personal scheduler can help ease the task load required in private practice and free up time for other endeavors.

Life-work balance will also be defined differently for every individual. If having total control over your schedule is important, then you should seek out a position that affords that opportunity. Many private practice set-ups will permit as much time off as needed if one’s overhead is covered for the group and call duties fulfilled. As previously mentioned, if you do not generate revenue through your work, you do not get paid. It is as simple as that.

Looking forward

The landscape of private practice will be forever changing. There have been concerns about the viability of private practice for decades and the concerns remain unchanged. In 2012 there were concerns that private practice was on “life support” from the overbearing regulations. The ability to run one’s own business and remain competitive on pricing while battling decreasing reimbursement can be overwhelming. Tackling reimbursement issues is a huge topic but it is one worth mentioning as it will affect your bottom line. While private practice has many upsides, the downsides need to be understood and embraced as they will be an equal part of your career.

Summary

All in all, private practice can be a wonderful and challenging endeavor for your career. Every job will have its pros and cons. Evaluate these! If you have a true understanding of your strengths and weaknesses and what it is you are looking for in a job, you can make an informed decision about where you would like to begin your career. I encourage you to rely on those you trust and seek advice from those who are knowledgeable. You will not find all of this information from a single source so reach out to as many people as possible to create your own approach. Take compassionate care of patients and you will reap the reward of good outcomes. Humility can also go a long way as the impressions left upon your patients play a large role in your relationship. Most importantly, maintain a life-work balance that fits your expectations and needs. Rarely do you hear folks wish they had worked more. Ideally, you want to avoid looking back on your career, wishing you had spent more time on the life side of that balance.