Quite a few medical students and residents find this blog, so I thought it would be good place for me to share my career advice for medical students. In 2009 I finished my residency in Family Medicine and sadly it wasn’t a good time to go into private practice with all the EHR which were about to hit and ACA coming on the scene.
Specialists in private practice
Primary care is now a specialty in the US but the readers should understand what I mean. Should you go into Family Medicine or IM or should you go into cardiology, orthopedics, or radiology?
Naturally, if you have a passion for a particular field, you should aim for that. For those who don’t gravitate towards a particular specialty, the decision should be a more calculated one.
Going out on your own as a specialist is, for the time being, a thing of the past. Opening your own private orthopedic practice or infectious disease practice is tough in many ways. The increasing regulation of healthcare and physicians makes it hard for these specialists to be successful in private practice.
Some specialists, dermatology, endocrinology, and rheumatologists can still manage to have private offices with some hospital affiliations. But this is an even tougher choice when you consider the student loan debt burden of 2019 and how long it takes to grow a private practice to a point of profitability.
Primary care in private practice
Hospital based practices are becoming very powerful and have come together to set the reimbursement rate for their services. Because of multiple recent health legislature, it’s hard for the smaller private practice groups to keep up.
But primary care doctors don’t have to be hospital affiliated. As a family medicine doctor, I don’t need to round in the hospital. I can see my patients in my private practice and let the hospitalists or ER doctors handle any inpatient needs.
But what’s tough with primary care is patient recruitment. If you live in the middle of nowhere, sure, you won’t have a tough time finding your patients …. unless an HMO has taken hold nearby. In the metropolitan areas, the hospital groups have a monopoly over the patient population.
One thing a private practice primary care doctor has going for them is a very low customer acquisition cost compared to back in the 1990’s or even early 2000’s. I can have a Facebook group or advertise on Reddit or use IG to advertise my services. But not every physician knows how to market themselves well – that’s a great topic for a podcast.
Student loan debt burden
A big factor for many doctors is their student loan debt. If you have $450k in student loan debt, you’re not going to be enticed by another $150k loan to start your private practice. You will also need a couple of years until you build your patient panel.
Since you will likely take insurance, whether you’re a primary care doctor or a specialist, you have to rely on the reimbursement rates for private health insurance groups, Medicare, and Medicaid, or Tricare.
Is it a coincidence that as student loan debt levels have risen, more physicians have chosen to be employed rather than having their own private practice?
Even worse, physician personal finance gurus constantly push student loan refinancing – likely because of heavy advertising on their platforms. This forces many physicians to extend the duration of their student loans, becoming a slave to their debt.
All career decisions are then based on whether that student loan payment can be made. Starting a private practice has some risks which the young physician will pass on because they have student loans.
Primary care or specialty care?
Let’s discuss where medicine is going before deciding whether you should become a specialist or a generalist.
We have the following trends:
- higher student loan debts
- rising interest rates
- increased health burden due to aging US population
- physician burnout
- rising healthcare costs
- ever stricter guidelines for the practice of medicine
- rising malpractice and medical board investigations
- rise of medical tourism
- marginal tax rates
I’m a family medicine trained physician. I can open a private practice and see anyone for anything. I can do prenatal care, I can deliver in a hospital, I can round on nursing home patients, I can take care of many in-office procedures, and I can manage chronic diseases regardless of what specialty they fall into.
As a primary care doctor I can earn at the very least $200,000. More realistically, $260k/year. And without too much effort I can get into the $320k range.
I can live anywhere in the US – I don’t have to be hospital or surgery center affiliated.
As a specialist I can see the patients with the conditions within my scope of practice – radiologist who reads films, orthopedist who manages musculoskeletal shit, dermatologist who handles skin issues, and ophthalmologist who handles eye related stuff.
The least you’ll earn as a specialist is $250k and you quickly ramp up quickly to $500k. Quite a few specialist can expect to earn $600k+ and many in the $800k/year range. But these numbers should be considered in light of our marginal tax bracket and the insanely high taxation rate as a high-income employee.
As a specialist, you need referrals. The private practice family medicine doctor will manage their own diabetics – you’re not going to get his referrals as an endocrinologist. Being hospital affiliated makes it easy, providing a continuous referral source.
If you’re a surgeon then you’ll need hospital affiliations. This can limit where you live because some areas just don’t have a lot of hospitals or are saturated with specialists. A hand surgeon might have a tough time finding a gig in a desirable part of the state.
Private practice business model
My shtick on this blog is to cut as much of your overhead as possible, pay down all your student loan debt ASAP, and buy everything with cash – even your home. I’m pretty much in the 1% minority of physicians living this kind of a lifestyle so take what I say with a grain of salt.
The advantage I have over other physicians, as a financially independent primary care doctor, is that I can go open a cash-based private practice and skip the whole insurance thing. It might take a while to build up my practice but at least the patient will get private care instead of getting shuffled through a massive hospital system. And I can fill my downtime with telemedicine.
I can also see patients online through telemedicine or specialize my practice as a concierge practice or take a more holistic approach. I can choose to see younger patients or I can specialize in older individuals.
A few specialists could achieve the same such as a rheumatologist, endocrinologist, dermatologist, ENT, or GI doctor. But it would be much tougher. Charging cash as a specialist is generally out of the question unless you can squeeze yourself into a very niche practice with a very affluent client base.
Medicine is only becoming more and more specialized and turning into an assembly line in a quick way. Some hospital groups hire orthopedic surgeons just to pump out knee replacements after knee replacements.
They might have psoriasis clinics where the poor dermatologists plow through 100 psoriasis patients and don’t get to practice anything else.
Assuming you don’t have a passion for a particular specialty, of course, I would have to lean towards primary care as a career choice for medical students. You will never starve, you’ll have a ton of practice flexibility, and you can either be an employee or go into private practice.
We’ve seen the income gap close between specialists and primary care doctors. Many predict that this will continue. Though if it’s all about the money to you, on the fringes you will find specialists earning millions of dollars a year. Then again, I know family medicine doctors with multiple clinics who earn >$1M/year.