AAOS Bulletin - February, 2006

Evaluating practice opportunities

Asking the right questions can help you avoid costly career missteps

By Ryan M. Dopirak, MD

The average orthopaedic surgeon will make two or three practice changes over the course of his or her career. Half of all orthopaedists will make a change within the first two years of joining a practice—a disruption that can result in increased stress, wasted time and lost income. Evaluating practice opportunities with a critical eye is crucial to avoid such costly mistakes.

This article, the first in a two-part series, provides a range of questions for orthopaedists to ask potential employers/partners when making important career decisions.

About the group and the Opportunity

1. Why are you recruiting a new orthopaedist?

The answer to this question can significantly affect your job satisfaction and financial bottom line. Acceptable reasons for hiring include the impending retirement of a senior partner, the desire to add a fellowship-trained subspecialist in an unrepresented area in the practice or the need to accommodate increasing patient volumes.

2. What type of practice is it?

Single specialty groups (SSGs) offer the most autonomy and entrepreneurial opportunity, but they do not provide a guaranteed referral base. The SSG income structure is usually productivity-based, with only a modest guarantee, and commonly requires a “buy-in” to partnership. Multispecialty groups (MSGs) provide an automatic referral base, but MSG orthopaedists often pay higher overhead than do their SSG peers.

Academic positions offer prestige and exposure—typically generating a high volume of patient referrals. Yet incomes for academic orthopaedists are usually lower than incomes for those in private groups. Academic orthopaedists are often required to take Level I trauma calls as well.

Hospital employment opportunities often entail competitive income guarantees, signing bonuses and student loan repayment. In most cases, employed orthopaedists also have an automatic referral base and receive assistance in marketing their practices. However, these physicians must report to hospital administrators, so there is less autonomy than in an SSG or MSG. Investment in ancillary ventures is also more complicated for hospital-employed physicians.

3. What is the ratio of orthopaedists to the local population?

The fewer orthopaedists, the busier your practice. In 2004, the average density of orthopaedic surgeons in the United States was 6.2 per 100,000 population, according to the latest AAOS Orthopaedic Physician Census. If surgeon density in your area is substantially higher, it may be difficult to develop a successful practice.

Statistics can be deceiving, though, so don’t automatically dismiss an opportunity with high surgeon density. Some local orthopaedists may be nearing retirement, others may not have a sound reputation or you may bring unique training or skills to the mix.

However, success isn’t assured in a low-density market either. Groups in neighboring communities may attract patients from your area, and established referral patterns may be difficult to change.

4. Will I be able to develop a practice in my subspecialty area, or must I practice general orthopaedics?

If you want to build a subspecialty practice, you need to determine if the market can support it. Most opportunities will require you to provide some general orthopaedic care and take some emergency room (ER) calls, regardless of fellowship training. However, you should have the right to decide what treatment areas are outside of your comfort level and transfer the care of those patients when appropriate.

Some groups may expect you to function as a true general orthopaedist for financial reasons—any patient who is turned away from the group is considered lost revenue. However, providing care to patients with disorders that are outside the realm of your training and abilities is ethically unacceptable and also increases your liability.

5. Which subspecialties are already represented within the group?

Obviously, your odds of establishing a practice are better if you have a unique subspecialty. If everyone in the group performs hip and knee replacement, it may take time for someone with a total joint fellowship to get established. In contrast, the only fellowship-trained spine surgeon in a group of 10 orthopaedists could quickly build a busy practice.

6. What is the future vision for the group?

Understand the group’s current and future plans for expansion of the practice. A general orthopaedist may hesitate to join a group that’s also recruiting a sports medicine fellow and/or a total joint fellow. For fellowship-trained orthopaedists, the ideal group will be comprised of other fellowship-trained surgeons in different subspecialty areas.

7. How are new patient referrals directed?

Nonspecific referrals may be assigned to physicians according to the chief complaint and subspecialty area, or the referral process may be hierarchical, with all new patients or consultations going to the senior partners. Ideally, referrals sent to a specific physician will be directed to that physician, and not redirected by chief complaint or seniority.

8. Does the contract include a restrictive covenant if I leave the group?

Contracts often include a “noncompete clause,” which states that if you leave the group, you agree not to practice in that geographic area for a certain period of time. You must determine if the terms and length of this provision are acceptable. If you have ties to a community and are not willing to relocate if you leave the group, you may wish to negotiate this clause.

9. Is there a “recapture clause” if I leave the group?

Compensation packages often include signing bonuses, student loan repayment and large income guarantees. Although such financial perks are appealing, they’re typically considered “forgivable loans,” meaning that a percentage of the total amount is forgiven each year over a set number of years. If you leave before fulfilling the terms of the contract, you may have to repay a portion of this money. Read the fine print!

10. Has anyone left the group in the past 10 years?

During the interview process, the group will be sure to point out their positive attributes. No job opportunity is perfect, however. Ask if anyone has left the group in the past 10 years, and if so, clarify the circumstances surrounding their departure. If you contact these former members, they may provide you with a very different perspective on the group.

11. Does the group employ physician assistants or nurse practitioners?

Physician extenders can increase patient volume in the outpatient setting and improve efficiency and outcomes in the operating room. However, they also increase overhead. Although billing separately for a physician assistant’s services is allowable for certain surgical procedures, fees generated directly by physician extenders may not always be sufficient to cover their full salaries and benefits. Consider whether the benefits of physician extenders outweigh the increased overhead.

12. What is the surgical caseload of each partner over the past few years?

Because orthopaedic income is directly related to surgical volume, you need to know each partner’s surgical caseload. According to AAOS census data, the average orthopaedist performs 31 procedures per month (372 per year), with subspecialists carrying a slightly higher surgical caseload than general orthopaedists.

About the on-call experience

1. How often is call and how is it divided within the group?

It’s crucial to understand expectations for ER call coverage. Some groups divide call equitably among all members, while others require the senior partners to take less call or no call at all, placing the burden on the younger physicians.

ER call may enable you to increase your caseload quickly, but it also increases demands on your time, and it will not necessarily help you to build a subspecialty-based elective practice. Call expectations and requirements should be clearly stated in the employment contract.

2. How many hospitals are included on call?

Orthopaedic groups frequently cover multiple hospitals. But if you have to make multiple trips to different hospitals to visit inpatients or to evaluate patients in the ER, your financial productivity, as well as your lifestyle, may suffer.

3. Is the hospital a “certified trauma center”?

If a hospital is a certified trauma center, it’s likely that trauma patients will be transferred from outside institutions on a regular basis. Because you will be held to the standard of care for orthopaedic traumatology, you must determine if you possess the necessary training and skills to provide trauma care.

On the positive side, providing orthopaedic trauma coverage may enable you to increase your caseload while you build your elective practice. Also, some hospitals compensate orthopaedic surgeons for taking trauma call.

4. How often are physicians called for middle-of-the-night emergencies?

Find out how busy the orthopaedists are while on call, and decide if this is compatible with your lifestyle expectations. Although this may be difficult to quantify objectively, consider the total number of annual ER visits, whether or not the hospital is a trauma center and the characteristics of the surrounding community. For example, in a largely industrial community, you can expect a relatively high volume of work-related hand injuries requiring orthopaedic care.

5. Does the group have established referral patterns for complex care?

Whether your hospital is a trauma center or not, patients with pelvis, acetabular and/or spine fractures will occasionally end up in your ER. Unless you’re a trauma specialist, you shouldn’t provide operative care to such patients. Make sure referral patterns are established so you can transfer care of complex trauma patients when appropriate.

6. Is the medical center equipped with digital radiology that can be accessed from home)?

Many medical centers are implementing a filmless Picture Archiving and Communication System (PACS) for digital imaging. PACS enables images taken from various modalities—X-ray, CT, ultrasound or MRI—to be captured, stored, retrieved, distributed, viewed and manipulated across a network, or in remote locations using a web browser. This technology enables orthopaedic surgeons to make well-informed decisions about ER patients from a remote site, reducing the number of unnecessary visits to the ER.

Ryan M. Dopirak, MD, is currently a fellow in orthopaedic sports medicine and arthroscopic surgery at the Southern California Orthopedic Institute. He welcomes questions and comments by e-mail at rdopirak@msn.com

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