When my son was asked if he wanted to become a doctor just like his dad, he responded that his dad was hardly ever home and that wasn’t the type of life he wanted. He’s now 40 years old and a graduate of law school. In spite of his business requiring a lot of travel, he does devote as much time as possible to his family.
Interestingly, I started a solo practice in oncology in the same communities twice. Initially, I interviewed with solo physicians (and there were only two) nearing retirement who were looking for someone fresh out of fellowship to take all weekday and weekend call as well as cover the practice during office hours. For that privilege, my annual salary would be $24,000.00!! There were only two multispecialty medical groups at the time, but the offers were similar. So I decided to do it myself (that was possible then). My wife and I took out a loan at a local bank which we paid off in seven years, celebrating the event by cremating the note, and we bought a home in the community. We raised our children in that home and still live there 36 years later.
Managed care and computers weren’t a requirement then. My practice grew to the point where 24/7 was becoming onerous. So I started a group which provided coverage, but times had changed. Managed care, PPO’s, EPO’s and those dreaded HMO’s with capitated payments based on per member per month calculations made for a lot of anxiety . I spearheaded the effort to form a multispecialty IPA to meet these challenges. This effort was scuttled by our hospitals that formed a rival IPA. My former partners and I tried to piece together a single specialty IPA in oncology with plans to be a county-wide organization. But lack of a collaborative culture ruined that attempt and my partnership dissolved.
Solo again. The new challenge was the burgeoning cost of managing the business of oncology. Managed care plans have replaced private insurance to a large extent, thus lowering reimbusements. Several chemotherapy agents are no longer feasible for us to provide and patients to buy. Computers are required and now mandated. Obviously survival of solo oncologists is questionable. My solution was to merge with two other established practices to form a larger group better positioned to deal with the era of ACO’s. So, as the senior member of the group, how do I advise young oncologists in this much more complex environment than I faced?
- Firstly, we cannot survive practicing in our own silos. We need to leverage large numbers to increase our purchasing and contracting power.
- Next, we have to truly collaborate. Government and health plans are justified in wanting to know what they’re getting for their money. This requires diagnostic and treatment pathways which we agree on.
- We have to listen to our patients who constantly provide us with constructive criticism. New technologies such as social media can give us tools for listening and promoting dialogue. The current (and first) issue of OncLive (formerly Oncology Net Guide); Vol 12, No 3; 3.11 contains an article called “Socializing Medicine; Oncology Joins Facebook Era” describes the proliferation of these technologies and why it is important for us to become familiar with them.
- I furnish copies of Michael Gerber’s “E-Myth Physician”, a short but excellent book has been very useful to oncologists embarking on the road to private practice. Although somewhat dated, he describes a new physician who is bitten by the entrepreneurial bug, which ultimately leads to his destruction. While this didn’t happen to me, I made plenty of mistakes in my career. I learned from my mistakes and hopefully others can too.
- The titles of the chapters in Gerbers book are revealing about what he considers important: “Money”, “Growth”, and so on. Basic financial knowledge and awareness of the economics of health care are also quite valuable.
There are three options for new oncologists:
- Stay in academics.
- Join a multi-specialty group
- Join a single specialty group, like mine.
Under the third choice, this last year has seen an exodus of oncologists joining with their local community hospitals usually under a Foundation Model. I must admit this is appealing to me as it may be to new oncologists facing this brave new world. Management and financing of the practice would no longer be my worry. I would take home a salary and work as much or as little as I want until retirement. But a young oncologist would have to start over as I did on two occasions, Neither was easy; today it would be almost impossible.