As I was channel surfing the other night, something caught my eye. It was the Discovery channel and I was looking at a huge herd of some hoofed animal. They looked pleasant enough and at peace with the world. Then a lioness came out of nowhere and whacked one of the older animals. Indeed, this particular life and death struggle on the Serengeti reminds me of why a group practice makes so much sense today. That lioness could just as easily have been an insurance company executive and the herd could have been the group practice. In this case, the herd, while homogenous from a species context, also surely contained significant heterogeneity as it relates to the individuals in that group. What was the lesson here? The group, if like-minded, will provide the individuals of that group many benefits including safety in numbers, stability and longevity. After practicing in a multidisciplinary group practice environment in Roanoke, Va., I recently moved back to my home state of California and joined Kaiser Permanente, the largest and most successful non-profit HMO group in the country. In 2002, the California Healthcare Foundation commissioned the California Physicians Survey, which was conducted by researchers at the University of California, San Francisco (UCSF) Center for the Health Professions. The survey found that in California about 20 percent of the primary care physicians and about 15 percent of the specialists worked in the Kaiser Permanente System. They found that these physicians consistently expressed more positive opinions about their medical practice as compared to other independent practitioners. As I noted before, there is safety in numbers. While the Kaiser system is a non-profit, it is regularly discussed among those in the know that if it were in fact a publicly held corporation, it would hold a spot in the top tiers of the Fortune 500. This kind of financial stability can only exist in larger, well-managed practices. When you are a member of one of these entities, you have the benefit of concentrating your energies into patient care with much less time and worry devoted to the actual nuts and bolts of practice management.
What About Compensation?
In general, you will be compensated quite fairly. In fact, most large multidisciplinary groups set up their pay scales based on Medical Group Management Association (MGMA) surveys and other similar compensation surveys. Additionally, most of these group practices offer rich retirement packages, time off without the need to worry about opportunity costs, reimbursement for CME conferences, etc. It becomes clear that joining one of these groups can make solid financial sense. You should also know that many group practices and HMOs now employ some sort of “pay for performance” incentive into your contract. In fact, the New England Journal of Medicine just published a report that found up to 90 percent of physicians in a survey of 252 HMO-based physicians had a pay for performance clause in their contracts.1
Emphasizing The Degree Of Professional Satisfaction
Having ready and convenient access to those in different disciplines is by far one of the greatest benefits of working for a multidisciplinary practice. It is such a privilege to be able to walk down the hall and pick the brain of an esteemed colleague when you are faced with a challenging patient presentation. This environment can also be the catalyst to set up grand rounds, journal club and other academic meetings that many people sorely miss after leaving their residency training programs. Since everyone in the group has the same goal of making the practice successful, the oft-cited “turf battle” is muted if not entirely eliminated in these situations. While there will always be a few physicians with antiquated perceptions and large egos, it has been my general experience that the large groups recognize the comprehensive skills and training of podiatric surgeons. This translates into very few instances of restriction of one’s scope of practice. You should also never expect to become lonely for patients in a multidisciplinary practice. That is not to imply that you will be so overwhelmed as to employ unsafe or poor care practices. In fact, because of the competitive marketplace today, modern HMOs have had to adapt by providing not just care but ensuring total patient satisfaction. This generally translates into manageable clinic and patent load schedules. I can think of nothing more frustrating than to have completed a high powered surgical residency program and then end up in a slow practice with limited pathology. I have heard this complaint from many of my peers. The worst part is that this limited practice style does not allow a podiatric surgeon to fully develop his or her medical and surgical skills. This can even be a cause of distress to recent grads when realize they may not have the cases or variety to qualify for surgical board certification. Therefore, I have always advocated to graduating residents that they consider working for a large HMO group. In this way, they will have an excellent starting salary, great benefits and a patient population that is satisfactory to maintain all of their professional goals.
Balance is the best part of joining a large group or HMO. When you have your “physician hat” on, you can delve fully into your practice, academic activities, resident teaching, etc. However, when your “doctor hat” is off, there is always time for your personal life. Clearly, each practice model has its own set of pros and cons. In a purely private practice model with one or two physicians, the potential for high incomes and greater autonomy certainly does exist. In the large group setting, you will lose some autonomy and you will probably never see incomes beyond the upper tiers of the MGMA surveys. However, you will have the ability to employ your practice style and you will have a rich and varied patient population. You will have time for and may even be encouraged to participate in resident training. You will have time for your personal interests and family. In one case I have seen, you may even have the opportunity to enter into the upper echelons of group practice management. In summary, group practices, and HMOs in particular, have had the reputation of being restrictive to the physician but, in fact, I have found the opposite to be true. Dr. Weinraub is a Fellow of the American College of Foot and Ankle Surgeons. He is a faculty member of the Department of Orthopaedics at Kaiser Permanente in Hayward, Calif. Dr. Weinraub can be contacted at firstname.lastname@example.org . Editor’s note: For related articles, see “The Ins And Outs Of Forming A Multispeciality Practice” in the April 2002 issue. Also check out the archives at www.podiatrytoday.com .
1. Rosenthal MB. Pay For Performance in Commercial HMOs. NEJM, 355:1895-1902, 2006.