December 2001 Bulletin

When it’s time to relocate

‘Go where the need is, compromise on location’

Orthopaedists tell how they improved their careers, home life

By Ron Clark, MD

As many physicians "hunker down" under the strain of decreasing reimbursements brought about by managed care plans, others have found that the best way to improve their orthopaedic career is to move. There once was a time when an individual would complete his or her medical training and then select a place to practice and settle down for a nice 30- or 40-year career. Locations for a career generally revolved around one’s hometown, or the hometown of the spouse, or perhaps a penchant for one of the coasts or mountains.

With the number of orthopaedic surgeons practicing in the United States at an all-time high, and the RAND study suggesting that there exists a surplus of orthopaedic surgeons, the luxury of building a successful orthopaedic practice in just any location no longer exists.

Managed care executives have understood that "hungry" surgeons will do just about anything to "get a case," including cutting their fees by 50 percent or more so they can "make it up on volume." There is nothing like an overabundance of providers to make the fee discounting of managed health care plans a guaranteed boon to an insurance company’s bottom line.

The fact that an orthopaedic community is made up of orthopaedists with varying ages and financial needs also affects the success of fee discounters. Where there are a lot of senior orthopaedists with 10 years of less to practice, the attitude of "I’m almost done, don’t rock the boat" prevails. For orthopaedists right out of training, the attitude of "I’m making more money than ever, what’s the problem?" prevails. Orthopaedists in their 40s and early 50s are the most likely to ask, "How am I going to survive?" It is no wonder that the states with the highest penetration of managed care happen to be the most densely populated states by physicians. It should also be no surprise that California, managed care and all, continues to be the number one employer for graduating orthopaedic surgeons.

So what happens to the orthopaedist who selects to practice in a geographically desirable, but highly competitive location? Some just accept that they will not make what others are making economically and consider themselves fortunate to live above the average person in a highly desirable location. Others become frustrated, not only from earnings well below the mean, but also from lack of sufficient surgical cases to feel competent and capable technically.

Here are a couple of examples of very capable young orthopaedic surgeons who joined practices out of their training experiences in highly competitive locations only to find that their goals and aspirations for a successful practice were not likely to be met. Each made a determination to seek their next practice location based on orthopaedic practice concerns before geographic concerns.

Gregory L. Peare, MD, is currently practicing in Yuma, Ariz., population 80,000 with a county population of 160,000. When Dr. Peare finished his residency in Texas in 1994, he and his wife wanted to go back to Arizona where they had both lived previous to his residency. Dr. Peare found what he thought would be an ideal practice situation joining two other surgeons, who were well established in the community, as an employee with an offer to become a partner in two years.

Although Tucson is not the most densely populated area in terms of orthopaedic surgeons, it has been a cornerstone for several HMOs that aggressively discounted physician reimbursement. Changes occurred so rapidly that even Dr. Peare’s senior partners were caught unprepared. After spending two years of hustling in order to try to establish himself in a busy metropolitan area, Dr. Peare decided that it was time to explore other options. After going on perhaps a dozen or so "interview" trips and assessing opportunities, he elected to stay within Arizona but move to a somewhat isolated area on the California and Arizona border.

Dr. Peare was able to find a retiring orthopaedic surgeon to get office space from and the other orthopaedic surgeons in the community were pleased to welcome another willing soul to the ER call schedule. With everyone in the orthopaedic community as "busy" as they want, collegiality is notably improved compared to Tucson. Dr. Peare’s excellent training and ability have allowed him to flourish in this somewhat desert location.

Without the highly managed and competitive metropolitan environment, Dr. Peare has seen his surgical caseload increase by 50 percent, but his income virtually double. He has become so busy that six months ago he brought in a physician’s assistant to help with the workload. His wife has commented that the improvement in Dr. Peare’s orthopaedic practice has made him a happier person. He no longer becomes stressed when he’s not busy and it’s made home life better.

What was the hardest part about making a move? Dr. Peare says going from being the junior associate to being the person in charge. It was difficult to actually start the practice and wonder if it would be successful. Dr. Peare had done his homework though and the area definitely needed the resources of another orthopaedic surgeon.

What advice would Dr. Peare give to others frustrated by metropolitan orthopaedics? "Go where the need is, compromise on the location," he said.

G. Bradford Wright, MD finished his orthopaedic training in 1992 on active duty for the United States Air Force. In 1996, he finished his required years of service and opted to move to a town in Utah so that his wife could live in the community of her family. Dr. Wright thought that he had arranged to join a large successful group there and they even listed his name with them in their yellow page ads as an associate. Just months before he was to start, he received a phone call from one of the senior members indicating that the group was going to have to rescind its employment offer because of the effects of managed care and their decreasing reimbursements.

Not deterred, Dr. Wright found another solo practitioner who had offices in Salt Lake City and Park City, and who was looking for an associate to build a sports medicine practice. Dr. Wright had worked with several distinguished sports medicine practitioners and had even been a team physician at the United States Air Force Academy.

Together these two energetic surgeons went about building a practice the old fashioned way, available, affable and able. Unfortunately, an established pattern of referrals, a politically charged medical environment and the presence of a highly managed care area made for very slow growth. Using the "if they will build it, they will come," philosophy, Dr. Wright and his partner organized a freestanding surgical center that is now owned by Healthsouth in Park City.

Unfortunately, despite the best of efforts, the over-saturated market would not support the two of them and Dr. Wright was not even keeping up with the debt service that the group’s expansionist vision had entailed. He found himself sharing every other night call at a very rural hospital in the mountains above Salt Lake City and covering trauma call six times a month between two additional hospitals in the valley. After three years he decided that there must be a better way. Being in the military, you meet a large number of other surgeons. Dr. Wright started networking with several of his colleagues trying to get an idea of what their post military practice had been like. He quickly discovered that many were making triple his own income in Utah.

Fortunately for Dr. Wright, one of his former associates had a growing group in Jackson, Tenn. and was looking to add another partner. Jackson is a hub community of a large manufacturing area. The two hospitals there have more than 800 licensed beds and 70 percent of the patients are drawn there from surrounding counties. While Jackson itself is smaller than 100,000 in population, it serves as a regional referral center. Most of Dr. Wright‘s new partners are new to Tennessee, as well. What they have all found is an underserved area that was in need of skilled providers.

Dr. Wright‘s quality of life is much better because of his four partners. He spends far less time taking ER call yet his surgical load is more than double what it was in Utah. Dr. Wright has been able to recover from the debts he incurred from his first practice location and now looks forward to finally having some discretionary income. His sense of professional self worth has been greatly enhanced since his move. He also has been able to resume a sports affiliated practice as the team physician for the University of Tennessee at Martin, a division 1AA school, as well as being one of the team physicians for the West Tennessee Diamond Jaxx, the AA affiliate of the Chicago Cubs

To others in situations similar to the experience of Dr. Wright in Utah, he offers the following suggestions. First, he said, "don’t be afraid to move, just do it." Look to network with other colleagues or associates for locations that have true defined needs for additional orthopaedists.

Ron Clark, MD, is in practice in Valparaiso, Ind.

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