“Have you lined up a job after fellowship?”
This is a common question among chief residents and fellows. In fact, I can’t think of anyone who was asking about searching for office real estate or hiring a medical assistant. The trend is to join an existing practice.
Only 12% of Orthopaedic Surgeons were in solo practice in 2018, down from 18% in 2012 (Figure 1, 2). Likewise, the number of Orthopaedic Surgeons in Orthopaedic groups decreased from 44% to 36%. Academic and Hospital-employed positions rose from 9% each to 14% and 17% respectively. As large hospital systems grow more powerful, small groups and solo practitioners have lost their negotiating power. The same surgery done by an employed physician generally makes more money than by a solo practitioner. In addition, larger hospital systems can offset the decline in physician reimbursement with revenue generated by the operating room, physical therapy, imaging, and internal referrals the ER and urgent care. Life’s gotten harder for the self-employed physician, and as reimbursements decline, fewer are willing to take on the responsibility of running their own practices along with the risk entailed. In 2012, 74% worked in systems where their income was directly related to their own work (solo practice, Ortho group, multispecialty group, and privademics) while 24% had salaries. By 2018, only 61% were in non-salaried positions and 49% were salaried. Given the rate at which groups have been bought by larger hospital systems and private equity groups, the trend can be presumed to have continued towards salaried positions.
Part-Time vs Full-Time Orthopaedic Surgeons
Part-time Orthopaedic Surgeons are more likely to be in solo private practice, where the decision lies solely with the surgeon. Full time Orthopaedic Surgeons tend to work in Orthopaedic groups and employed by hospitals. However, total hours worked in solo versus hospital employed practice are roughly the same.
Full-time Orthopaedic surgeons work an average of nearly 53 hours per week, while those who work part-time have an average of about 23 hours per week. Orthopaedic surgeons have many reasons to work part-time, including family, other business ventures, ease into retirement, and nonclinical work. The freedom afforded by private practice is valuable for innovation in our field, prevention of burnout, and the ability to focus on other aspects of our lives. These intangibles are difficult to defend in employed positions but are critical to the future of our field.
It is well-documented that loss of autonomy at work is a major driver or physician burnout. The ability to choose how many hours to spend at work and how to spend those hours can vastly improve the mental health of Orthopaedic surgeons. While other fields are embracing the ability to work clinically part-time, Orthopaedics remains a largely full-time field. Less than 10% of practicing Orthopaedic surgeons work part-time. Ancillary non-clinical work can provide a means to cut back on hours and avoid burnout.
BENEFITS OF RUNNING A SOLO PRACTICE
Running a thriving solo practice in a high cost of living area essentially requires ancillary income, but the benefits of choosing your patients, choosing your hours, and choosing how you practice are the valuable rewards.
Many physicians assume that the only means to financial stability is through W-2 employment for their clinical practices. The hospitals and large groups they work for offset the declining reimbursements with built-in ancillaries, have negotiating power for better reimbursement rates, and can minimize their own overhead with efficient systems. However, the trade-off is a physician’s freedom and autonomy to drive his or her own practice. With ancillary income that is not reliant on insurance reimbursements, a physician has greater options for practice building.
Purchasing medical equipment, shares in surgicenters, or real estate requires significant upfront cost that is not realistic for many physicians recently out of training, especially in high cost of living areas. Lenders are becoming reticent to provide funding without significant history in business.
Use of an orthopaedic surgeon’s clinical skill in the legal world, where reimbursements for our expertise are greater than in clinical practice, is one excellent way to find financial freedom.